Does augmented core decompression decrease the rate of collapse and improve survival of femoral head avascular necrosis? Case-control study comparing 184 augmented core decompressions to 79 standard core decompressions with a minimum 2 years' follow-up

X-ray, digital tomographic fusion, CT, and MRI in early ischemic necrosis of the femoral head

To investigate the imaging performance of radiography, digital tomographic fusion (DTS), computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis of early avascular necrosis of the femoral head (ANFH). A total of 220 patients with ANFH who visited our hospital from January 2020 to January 2022 were included in the study. X-ray, DTS, CT, and MRI examinations of both hips were performed for all patients. The trabecular structure, bone density changes, femoral head morphology, and joint space changes were observed using the aforementioned imaging modalities. The staging was performed according to the Association Research Circulation Osseous (ARCO) criteria. The diagnostic detection rate of each imaging modality, and the sensitivity, specificity, positive predictive value, and negative predictive value of each examination for diagnosing early ANFH were calculated and compared. Patients were diagnosed with stage I (n = 65), stage II (n = 85), stage III (n = 32), and stage IV (n = 38) ANFH. For MRI, the detection rate (97.7%), sensitivity (94.7%), specificity (88.6%), positive predictive value (95.9%), and negative predictive value (92.5%), for diagnosing early ANFH, were significantly higher than those of other imaging methods (P < .05). MRI is the most accurate and sensitive imaging method for diagnosing early ANFH and has important clinical applications.

The indications for core decompression surgery in patients with ARCO stage I-II osteonecrosis of the femoral head: a new, comprehensive prediction system

Background

Core decompression (CD) is considered the most popular treatment method for patients with Association Research Circulation Osseous (ARCO) stage I-II osteonecrosis of the femoral head (ONFH). However, the definitive indication for CD is currently not well established.

Methods

This was a retrospective cohort study. Patients who were diagnosed with ARCO stage I-II ONFH and who underwent CD were included. According to the prognosis, the patients were divided into two groups: collapse of the femoral head after CD and noncollapse of the femoral head. Independent risk factors for the failure of CD treatment were identified. Subsequently, a new scoring system that included all these risk factors was built to help estimate the individual risk of CD failure in patients who were planning to undergo CD.

Results

The study included 1537 hips after decompression surgery. The overall failure rate of CD surgery was 52.44%. Seven independent prognostic factors for failed CD surgery were identified, such as male sex (HR = 75.449; 95% confidence interval (CI), 42.863-132.807), Aetiology (Idiopathic HR = 2.762; 95% CI, 2.016–3.788, Steroid-induced HR = 2.543; 95% CI, 1.852–3.685), if the patient had a seated occupation (HR = 3.937; 95% CI, 2.712–5.716), age (HR = 1.045; 95% CI, 1.032–1.058), haemoglobin level (HR = 0.909; 95% CI, 0.897–0.922), disease duration (HR = 1.217; 95% CI, 1.169–1.267) and the combined necrosis angle (HR = 1.025; 95% CI, 1.022–1.028). The final scoring system included these seven risk factors, and the area under the curve of this scoring system was 0.935 (95% confidential interval = 0.922–0.948).

Conclusion

This new scoring system might provide evidence-based medical proof for determining whether a patient with ARCO stage I - II ONFH might benefit from CD surgery. This scoring system is crucial for making clinical decisions. Consequently, this scoring system is recommended before CD surgery, which could help determine the potential prognosis of patients.

Avascular necrosis of the femoral head: three-dimensional measurement of drilling precision reveals high accuracy and no difference between fluoroscopically controlled core decompression and cancellous bone grafting

INTRODUCTION

Avascular osteonecrosis of the femoral head (AVN) is a widespread disease affecting mostly young and active people, often exacerbating in progressive stages, ending in joint replacement. The most common joint preserving operative therapy for early stages is core decompression (CD), optional with cancellous bone grafting (CBG). For success it is vital that the necrotic area is hit and the sclerotic rim is broken by drilling into the defect zone to relieve intraosseous pressure. The aim of this study was to investigate if both techniques are precise enough to hit the center of the necrosis and if there is a difference in precision between drilling with small pins (CD) and the trephine (CBG).

PATIENTS AND METHODS

10 patients underwent CD, 12 patients CBG with conventional C-arm imaging. Postoperatively 3D MRI reconstructions of the necrotic area and the drilling channels were compared. The deviation of the drilling channel from the center of the necrotic area was measured. PROMs (HHS, HOOS, EQ-5D, SF-36) were evaluated to compare the clinical success of these procedures.

RESULTS

Neither with CD nor with CBG the defect zone was missed. The drilling precision of both procedures did not differ significantly: distance to center 3.58 mm for CD (range 0.0-14.06, SD 4.2) versus 3.91 mm for CBG (range 0.0-15.27, SD 4.7). PROMs showed no significant difference.

CONCLUSION

Concerning the most important difference between the two procedures-the surgical higher demanding technique of CBG-we suggest applying the less invasive technique of CD alone.

Comparison of current treatment strategy for osteonecrosis of the femoral head from the perspective of cell therapy

Aims: The purpose of our study is to compare the effects of core decompression (CD) and bone grafting (BG) on osteonecrosis of the femoral head (ONFH). And evaluate the efficacy of CD based on cell therapy to provide guidance for the dose and number of cells. Methods: We searched PubMed, Embase, and the Cochrane Library between 2012 and 2022, with keywords including "osteonecrosis of the femoral head", "core decompression" and "bone grafting". We selected comparative studies of CD and BG, and the comparison of CD combined with bone marrow (BM) transplantation and CD alone. Changes in hip pain were assessed by VAS, hip function were assessed by HHS and WOMAC, and THA conversion rate was used as an evaluation tool for femoral head collapse. From these three aspects, the dose of bone marrow and the number of cells transplantation were subgroup analyzed. Results: Eleven studies were used to compare the efficacy of CD and BG. There was no significant difference in HHS, and the THA conversion rate of BG was significantly lower than that of CD. Thirteen CD studies based on cell therapy were included in the meta-analysis. Bone marrow aspiration concentrate (BMAC) can significantly improve VAS (mean difference (MD), 10.15; 95% confidence intervals (CI) 7.35 to 12.96, p < 0.00001) and reduce THA conversion rate (odds ratio (OR), 2.38; 95% CI 1.26 to 4.47, p = 0.007). Medium dose bone marrow fluid has a lower p-value in THA conversion rate. The p values of bone marrow mononuclear cells (BMMC) of 10⁹ magnitude in VAS score were lower. Conclusion: In general, there is no consensus on the use of BG in the treatment of ONFH. The enhancement of cell-based CD procedure shows promising results. Using 20 mL BMAC and 10⁹ magnitude BMMC is likely to achieve better results.

Analysis of Factors Influencing Postoperative Femoral Head Collapse in Patients With Ficat I, II, and III Stages of Aseptic Necrosis of the Femoral Head

OBJECTIVE

To investigate the factors influencing postoperative femoral head collapse (FHC) in patients with Ficat I, II, and III stages of aseptic necrosis of the femoral head (ANFH).

METHODS

Retrospective analysis of 178 patients with ANFH admitted to our hospital from October 2018 to October 2021 was studied, and patients were categorized into the FHC group and no FHC group according to whether FHC occurred after surgery. The influencing factors causing postoperative FHC were analyzed by univariate and multifactor logistic regression.

RESULTS

In the collapsed group, there were statistically significant differences in etiology, extent of necrosis, mechanism of injury, preoperative waiting time, Japanese Femoral Necrosis Research Society staging, distance from the tip of the tantalum rod to the center of necrosis, and Harris score after treatment ( P < 0.05). The etiology, extent of necrosis, mechanism of injury, preoperative waiting time, Japanese Femoral Osteonecrosis Research Society classification, distance between the tantalum rod tip and the center of necrosis, and Harris score after treatment were set as independent variables, and postoperative FHC in patients with Ficat I, II, and III stages of ANFH was used as the dependent variable in the univariate logistic regression analysis.

DISCUSSION

Hormonal osteonecrosis of the femur, extent of necrosis, type C1 and type C2 in the Japanese Society for the Study of Femoral Osteonecrosis staging, and distance of the tip of the tantalum rod from the center of necrosis are risk factors for postoperative FHC in patients with Ficat I, II, and III stages of ANFH.

Femoral Head Necrosis Due to Brucella Infection in China: Case Series and Literature Review

Introduction

The causes of femoral head necrosis mainly include trauma, corticosteroid, and alcohol, among which Brucella is highly unusual.

Patients and Methods

This paper reported three rare cases of femoral head necrosis due to Brucella, summarizing and analyzing the epidemiological history, clinical manifestations, laboratory examinations, imaging findings, individualized therapy, and biopsy results of patients with this disease. A literature review related to brucellosis and femoral head necrosis was conducted.

Results

All three patients had an epidemic history of brucellosis. They suffered from hip pain and limitation of movement for months, and femoral head necrosis was confirmed by magnetic resonance imaging (MRI). Pathological Giemsa staining or real-time polymerase chain reaction (real-time PCR) confirmed Brucella melitensis (B. melitensis) as the cause of osteonecrosis. Each patient received individualized therapy according to the degree of osteonecrosis, which was based on anti-brucellosis medications and hip puncture and irrigation decompression. They were followed up for more than two years and rehabilitated well.

Conclusion

Brucella infection should always be considered the cause of femoral head necrosis for patients with hip pain, especially for those with an epidemic history; early diagnosis and individual stepwise therapy can prevent the progression of osteonecrosis.

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

Bone forage to treat early osteonecrosis of the femoral head (ONFH) has evolved as the channel to percutaneously deliver cell therapy into the femoral head. However, its efficacy is variable and the drivers towards higher efficacy are currently unknown. The aim of this study was to evaluate the forage technique and correlate it with the efficacy to heal ONFH in a multicentric, multinational clinical trial to implant autologous mesenchymal stromal cells expanded from bone marrow (BM-hMSCs). Methods: In the context of EudraCT 2012-002010-39, patients with small and medium-sized (mean volume = 13.3%, range: 5.4 to 32.2) ONFH stage II (Ficat, ARCO, Steinberg) C1 and C2 (Japanese Investigation Committee (JIC)) were treated with percutaneous forage and implantation of 140 million BM-hMSCs in a standardized manner. Postoperative hip radiographs (AP—anteroposterior and lateral), and MRI sections (coronal and transverse) were retrospectively evaluated in 22 patients to assess the femoral head drilling orientation in both planes, and its relation to the necrotic area. Results: Treatment efficacy was similar in C1 and C2 (coronal plane) and in anterior to posterior (transverse plane) osteonecrotic lesions. The drill crossed the sclerotic rim in all cases. The forage was placed slightly valgus, at 139.3 ± 8.4 grades (range, 125.5–159.3) with higher dispersion (f = 2.6; p = 0.034) than the anatomical cervicodiaphyseal angle. Bonferroni’s correlation between both angles was 0.50 (p = 0.028). More failures were seen with a varus drill positioning, aiming at the central area of the femoral head, outside the weight-bearing area (WBA) (p = 0.049). In the transverse plane, the anterior positioning of the drill did not result in better outcomes (p = 0.477). Conclusion: The forage drilling to deliver cells should be positioned within the WBA in the coronal plane, avoiding varus positioning, and central to anterior in the transverse plane. The efficacy of delivered MSCs to regenerate bone in ONFH could be influenced by the drilling direction. Standardization of this surgical technique is desirable.