Clinical study on minimally invasive treatment of femoral head necrosis with two different bone graft materials

Advancements in 3D printing technologies for personalized treatment of osteonecrosis of the femoral head

Three-dimensional (3D) printing technology has shown significant promise in the medical field, particularly in orthopedics, prosthetics, tissue engineering, and pharmaceutical preparations. This review focuses on the innovative application of 3D printing in addressing the challenges of osteonecrosis of the femoral head (ONFH). Unlike traditional hip replacement surgery, which is often suboptimal for younger patients, 3D printing offers precise localization of necrotic areas and the ability to create personalized implants. By integrating advanced biomaterials, this technology offers a promising strategy approach for early hip-preserving treatments. Additionally, 3D-printed bone tissue engineering scaffolds can mimic the natural bone environment, promoting bone regeneration and vascularization. In the future, the potential of 3D printing extends to combining with artificial intelligence for optimizing treatment plans, developing materials with enhanced bioactivity and compatibility, and translating these innovations from the laboratory to clinical practice. This review demonstrates how 3D printing technology uniquely addresses critical challenges in ONFH treatment, including insufficient vascularization, poor mechanical stability, and limited long-term success of conventional therapies. By introducing gradient porous scaffolds, bioactive material coatings, and AI-assisted design, this work outlines novel strategies to improve bone regeneration and personalized hip-preserving interventions. These advancements not only enhance treatment efficacy but also pave the way for translating laboratory findings into clinical applications.

Hip joint-preserving strategies for treating osteonecrosis of the femoral head: From nonoperative to operative procedures

Osteonecrosis of the femoral head (ONFH) has an exceedingly high prevalence and disability rate, causing a tremendous socioeconomic burden. The prevalence of ONFH is increasing, while the population of the patients with ONFH is becoming younger. Once the femoral head collapses, treatment becomes difficult and often requires a hip joint replacement, which is not favorable for young patients. Therefore, hip joint-preserving treatments at an early stage of ONFH are particularly important. This study provides a comprehensive review on hip-preserving strategies for treating ONFH, including nonoperative treatments (e.g., protective weight bearing, hyperbaric oxygen, pulsed electromagnetic, extracorporeal shockwave, bisphosphonate, anticoagulants, hypolipidemics, vasodilators, and traditional Chinese medicine) and operative treatments (e.g., core decompression, osteotomy, bone grafting, mesenchymal stem cell transplantation, tantalum rods, and tissue engineering). Nonoperative treatments aim to slow down the progression of the disease and delay the need for joint replacement; however, they usually cannot effectively prevent the progression of the disease, except in cases of small necrosis areas (<10 %). Additionally, nonoperative treatments have unclear mechanisms that require further investigation. In contrast, operative treatments may stop the negative outcomes of necrosis and therefore appear to be more promising. Currently, an emerging area in operative treatments is regenerative medicine, which could promote the generation of bone tissues and blood vessels and restore hip joint function to pre-necrotic levels as much as possible. This review seeks to not only provide an important reference for clinicians when choosing appropriate strategies for treating ONFH but also offer certain guidance for future basic research in developing ONFH treatments.

The translational potential of this article

The incidence of ONFH is increasing, and patients are becoming younger on average. Therefore, the development of hip joint-preserving strategies to treat ONFH at earlier stages is urgently needed, particularly for young patients. However, a comprehensive review is lacking regarding the currently-available hip joint-preserving strategies and their effectiveness. This study is motivated to fill this gap and serve as an important reference for clinicians in choosing appropriate strategies to treat ONFH.

Evaluating the clinical potential of bioceramic-rods for revascularization in osteonecrosis of the femoral head: a systematic review

OBJECTIVE

To evaluate the safety, reliability, and effectiveness of bioceramic rods (BR) in treating osteonecrosis of the femoral head (ONFH), compared with other treatments such as core decompression and autologous bone grafting.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Pubmed, Embase, and CNKI databases from January 2011 to July 2023.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Included studies involved patients treated with bioceramic rods. Studies were required to have a follow-up time of more than six months and no statistically significant differences in baseline information between groups in controlled studies. Exclusions included literature reviews, case reports, conference abstracts, animal experiments, and studies without defined success criteria or lacking analysis on factors influencing efficacy.

MAIN OUTCOME MEASURES

The primary outcome measure was the Harris Hip Score (HHS) improvement rate. Secondary outcomes included the femoral head stability and survival rate, alongside the hip replacement rate.

RESULTS

The systematic review revealed significant improvements in symptom relief and functional recovery using BR for the treatment of ONFH. An average follow-up of 20.44 months showed an overall HHS improvement rate of 33.93%. Hip preservation efficacy with BR was superior to core decompression and autologous bone grafting. The overall femoral head survival rate was 84.42%, with results sustained for three years. The success rate of hip preservation was notably higher with early intervention, which showed better outcomes when the overall HHS improvement exceeded 27%, and rates of excellent and good outcomes approached 90%.

CONCLUSIONS

Bioceramic rods offer a safe, minimally invasive, reliable, and effective treatment option for ONFH, ensuring substantial symptom relief and functional recovery. The technique's success in early disease stages suggests a strong potential for broader clinical adoption. Although additional benefits from combining BR with stem cells, platelet-rich plasma, and traditional Chinese medicine are noted, definitive conclusions on enhanced therapeutic effects remain inconclusive.

Comparison of the Efficacy of Different Combined Therapies Based on Modified Core Decompression for the Treatment of Early-stage Nontraumatic Osteonecrosis of the Femoral Head: A Retrospective Clinical Study

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a severe orthopedic disease, which may cause severe hip dysfunction in later stage. Therefore, it is necessary to treat nontraumatic ONFH during the early stages. The aim of this study was to evaluate the clinical efficacy and survival rates of different combined therapies based on modified core decompression (CD) for early-stage nontraumatic ONFH.

METHODS

This retrospective cohort study assessed 397 hips with ONFH who underwent different combined therapies based on modified CD in our institution between January 2010 and December 2017. Patients were classified into six groups based on treatment modalities, and were followed up at 1 year and 5 years postoperatively. Clinical outcomes, including Harris hip score (HHS) and Western Ontario and McMaster Universities osteoarthritis index (WOMAC), were compared to evaluate the hip function and quick rehabilitation effect. Radiographic progression of ONFH and the incidence of total hip arthroplasty were analyzed to evaluate the survival rate of ONFH postoperatively. Statistical analyses were mainly performed with Kruskal-Wallis test, chi-square test and Kaplan-Meier method.

RESULTS

HHS increased significantly in all groups but showed no significant differences among the six groups in the first years. The nonvascularized allogeneic fibula with bone grafting (NVAF + BG) and percutaneous femoral neck-head fenestration with bone grafting via the direct anterior approach (DAA + BG) groups had significantly higher HHS (p = 0.010; p = 0.025) and WOMAC function score (p < 0.001; p = 0.012) than the CD group 5 years postoperatively. Compared with the CD group, all the other groups showed statistically significant differences in radiographic progression (p < 0.001) and a higher survival rate with no significant difference (p = 0.569).

CONCLUSION

Our study demonstrates the potential use of NVAF + BG and DAA + BG, may serve as a promising combined therapy for the treatment of early-stage nontraumatic ONFH.

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.

One in five patients require conversion to arthroplasty after non-vascularized bone grafts in patients with osteonecrosis of the femoral head: a systematic review

BACKGROUND

Non-vascularized bone grafting (NVBG) has demonstrated to treat osteonecrosis of the femoral head (ONFH). There are a number of articles updating the use of NVBG to treat the ONFH, but the percentage of patients subsequently undergoing a total hip arthroplasty (THA) is controversial.

METHODS

Several electronic databases, including PubMed, Embase, Web of Science, and Cochrane databases, were searched to find studies using NVBG to treat ONFH. The pooled rate and 95% confidence interval (CI) were used to assess the conversion rate to THA after NVBG. In addition, we performed subgroup, sensitivity, and publication bias analysis.

RESULTS

A total of 37 studies describing 2599 hips were included. The mean weighted follow-up time was 50.5 months and the mean age at surgery was 36.3 years. The conversion rate to THA after NVBG was 21% (95%CI: 17% to 25%), and subgroup analyzes indicated lightbulb, trapdoor and Phemister techniques incidences with THA of 15%, 19%, and 24%, respectively.

CONCLUSIONS

This study preliminarily obtained the general trend of the survival rate of NVBG patients, but these results should be interpreted cautiously. Pooled results from 2599 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 21% of patients underwent a THA following NVBG. NVBG treatment for patient with ONFH appears to defer or at least delay the need for THA.

Effect of miR-222 on the Angiogenesis of Bone Microvascular Endothelial Cells After Repair of Vascular Endothelial Growth Factor with Polylactide-Poly(ethylene glycol)-Polylactide (PELA) Microspheres

The objectives of this study were to show the effect of miR-222 expression on angiogenesis and the mechanism of angiogenesis differentiation of bone microvascular endothelial cells. For the study, the concentration of VEGF release was detected by ELISA, and cell activity was shown using a CCK-8 (Cell Counting Kit-8). We used western blotting to detect VEGFR, TGF-β, and bFGF expression. The results showed that miR-222 expression by day 14 was significantly lower compared to the expression results for days 3 and 7. Additionally, miR-222 expression on day 7 was significantly lower than on day 3. MiR-222 expression in the control group and PELA group decreased gradually over time. On day 14, miR-222 expression in the VEGF microcapsule scaffold group was at its lowest level. Our conclusions were that the regulation of the angiogenesis of bone microvascular endothelial cells appears to be related to (1) the effect of miR-222 on VEGFR and TGF-β, and (2) how bFGF expression is regulated.

An all-arthroscopic light bulb technique to treat osteonecrosis of the femoral head through outside-in fashion without distraction: A case report

The technique of distraction has been widely used in hip arthroscopy for opening joint spaces. However, an all-arthroscopic light bulb technique through outside-in fashion without distraction has not been reported for the treatment of osteonecrosis of the femoral head (ONFH). A 29-year-old man was admitted to our department with hip pain and limited range of motion (ROM) in both hips over 4 months. X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) showed a mixed appearance, including sclerosis and cysts on the anterosuperior site of the bilateral femoral heads. The patient had an 11-year history of liquor intake. In addition, no other pathologies were found before the operation. After diagnosing bilateral ONFH (stage II) according to the Ficat classification, the patient underwent an all-arthroscopic light bulb technique through outside-in fashion without distraction because of failing conservative treatment. At the 2-year postoperative follow-up, the patient had neither pain nor limitation of ROM. The postoperative x-ray, CT, and MRI revealed a well-healed area of the previous bone grafting in the bilateral femoral heads. An all-arthroscopic light bulb technique through outside-in fashion without distraction can be a feasible method for the treatment of early-stage ONFH. This case reminds us that distraction- and perforation-related complications may be avoided in patients with ONFH without the concomitant pathologies of the central compartment.

Comparison of the outcome of different bone grafts combined with modified core decompression for the treatment of ARCO II stage femoral head necrosis

PURPOSE

Treatment of ONFH at an early stage is a challenging issue. The modified minimally invasive core decompression combined with bone graft implantation remains controversial. This study aimed to compare the early-middle outcomes of four groups with different bone grafts.

METHODS

A total of 182 patients (192 hips) with ONFH at the ARCO II stage were randomly divided into four groups. The free fibular graft group (FFG), free vascularized fibular graft group (FVFG), autologous iliac bone group (ABG), and β-tricalcium bioceramics phosphate graft (β-TCPG) group. Each group was treated with the modified minimally invasive core decompression and bone graft implantation. The operation time and blood loss were recorded by the same observer. The clinical outcome was evaluated by the Harris Hip Score and VAS score (before, 14 days after surgery, and at the last follow-up). The radiographic progression of ONFH was evaluated at least 36 months of follow-up.

RESULTS

All cases were successful without any complications after the operation. The patients were followed up for 42 to 48 (44.62 ± 1.81) months. There were statistically significant differences among the four groups in operation time (F value = 1520.67; P < 0.01) and blood loss (F value = 5366.81; P < 0.01). The Harris Hip Score in each group was improved significantly from pre-operation to last follow-up (all P < 0.01). At the last follow-up, the difference in the Harris Hip Score in each group was not statistically significant (F value = 0.54; P = 0.984). The VAS scores in each group were decreased significantly from the pre-operation to14 days after surgery (all P < 0.01). At 14 days after surgery, the difference in the VAS score in each group was not statistically significant (F value = 0.64; P = 0.59). At the last follow-up, three hips collapsed on the femoral head in the FFG group, two in the FVFG group, two in the ABG group, and three in the β-TCPG group.

CONCLUSION

The four different bone graft implantation showed satisfactory early-middle outcomes. As compared to other bone grafts, the β-TCP bioceramics graft has the advantages of shorter operation time and lesser blood loss. It may be a choice as a bone graft for the treatment of ONFH at an early stage.

Treatment of pre-collapse non-traumatic osteonecrosis of the femoral head through Orthopdische Chirurgie München approach combined with autologous bone mixed with β-tricalcium phosphate porous bioceramic bone graft: a retrospective study of mid-term results

Background

This study aimed to evaluate the clinical efficacy of femoral head and neck fenestration combined with autologous bone mixed with β-tricalcium phosphate porous bioceramic bone (light bulb procedure) through Orthopdische Chirurgie München approach (OCM approach) for pre-collapse non-traumatic osteonecrosis of the femoral head(ONFH).

Methods

The clinical data of 47 patients (47 hips) with ONFH were retrospectively reviewed. The Harris hip score (HHS) was used to evaluate the clinical outcomes. Imaging was assessed by X-ray. Clinical failure was defined as postoperative total hip arthroplasty (THA) or the HHS was poor (< 70). The Kaplan–Meier survival curve was used to conduct a univariate analysis of risk factors. The analysis factors included gender, age, International Association Research Circulation Osseous (ARCO) stage, etiology, body mass index (BMI), 25-hydroxyvitamin D (25(OH)D), and type I collagen carboxy-terminal peptide (CTX). The COX multivariate risk model was used to analyze the risk factors.

Results

All the 47 hips were followed up for 24–58 months, with an average of 45 months. The Harris score (76.29 ± 10.38) at the last follow-up was significantly higher than the preoperative HHS (64.45 ± 2.93) (P < 0.05). The postoperative HHS was excellent with a success rate of 36.17%. Postoperative imaging evaluation showed that 9 hips improved, 28 hips stabilized, and 10 hips progressed. Moreover, 17 out of 47 hips were defined as a postoperative clinical failure and the success rate was 63.83%. 25(OH)D and preoperative ARCO stage were risk factors for postoperative clinical failure (P < 0.05). The COX multivariate risk model analysis showed that IIIA stage was an independent risk factor for postoperative clinical failure (P < 0.05).

Conclusions

The head and neck fenestration and bone grafting via the OCM approach in the treatment of non-traumatic ONFH in the pre-collapse stage can achieve good clinical outcomes. 25(OH)D deficient patients and ARCO IIIA patients had a higher failure rate of bone graft using this approach.