Lantern-shaped screw loaded with autologous bone for treating osteonecrosis of the femoral head

Comparative analysis of surgical interventions for osteonecrosis of the femoral head: a network meta-analysis of randomized controlled trials

BACKGROUND

Despite several surgical options, there remains no consensus regarding the optimal approach for osteonecrosis of the femoral head (ONFH), a prevalent and refractory disease. To determine the most suitable treatment modality, we compared randomized controlled trials (RCTs) that evaluated multiple surgical treatments for ONFH using a Bayesian network meta-analysis (NMA).

METHODS

The outcomes of 11 different surgical treatments were assessed using NMA comparisons of the rate of progression of femoral head necrosis, the rate of conversion to total hip arthroplasty, and improvement of the Harris hip score (HHS). A random effects model was used to analyze the odds ratio (OR) or mean difference, and risk of bias was assessed using the Cochrane risk of bias assessment tool for randomized trials. The confidence of the results was assessed using the confidence in network meta-analysis tool.

RESULTS

A total of 18 RCTs were included in the meta-analysis. Compared with core decompression (CD), the forest plot showed that autologous bone grafting (ABG), free fibula grafting (FFG), vascularized bone grafting (VBG), autologous bone grafting combined with bone marrow aspirate concentrate (ABG + BMAC), and biomaterial grafting combined with vascularized bone grafting (BMG + VBG) delayed ONFH progression. Among them, ABG + BMAC showed the most promising results (OR 0.019; 95% confidence interval [CI] 0.0012-0.25). However, upon comparing CD with different surgical modalities, no significant differences were found in preventing total hip arthroplasty. Furthermore, we cannot draw conclusions regarding the HHS due to attribution and high heterogeneity across the studies.

CONCLUSION

Overall, ABG, VBG, FFG, ABG + BMAC, and BMG + VBG showed significant results in preventing ONFH progression compared with that shown by CD. Based on the surface under the cumulative ranking, ABG + BMAC was the most effective. Moreover, all treatments involving bone grafting were found to be effective, possibly indicating the necessity of its use in the treatment of 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.

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.

Evaluation of Radiographic Outcomes after Core Decompression for Osteonecrosis of the Femoral Head: The Beijing University of Chinese Medicine X-ray Evaluation Method

BACKGROUND

Joint-preserving treatments for osteonecrosis of the femoral head (ONFH) are an area of significant interest in orthopaedics as they may restore function and provide durable benefit to patients who would otherwise require early total hip arthroplasty. Studies reporting the outcomes for these procedures generally rely on a combination of radiographic and clinical outcomes. However, there is not currently a standardized radiographic scoring system that allows for objective reporting of radiographic outcomes following these procedures. This article introduces a novel scoring system (Beijing University of Chinese Medicine X-ray evaluation, BUCMXE) based on Anteroposterior (AP) hip radiographs to allow for objective evaluation and comparison of postoperative outcomes following joint-preserving treatments for ONFH.

METHODS

The proposed scoring system utilizes AP radiographs of the hip and consists of a total score (0-10) derived from the sum of subscores in 3 domains: femoral head morphology, osteonecrotic lesion, and degree of osteoarthritis. Each radiographic parameter is scored from 0 (normal) to 3 or 4 (advanced disease). The scoring model was retrospectively applied to a cohort of patients who had undergone core decompression and cancellous bone grafting procedures by the principal investigator.

RESULTS

The BUCMXE provided a clear and reproducible means of quantifying and communicating radiographic changes over the course of follow-up in our study cohort. Statistical analysis demonstrated that the BUCMXE was sensitive to detect the radiographic changes associated with the index procedure. The median total score was reduced from 3 preoperatively to 2 at the initial (3-month) follow-up for this cohort. This change was attributable to the obvious improvement of osteonecrotic lesion in patients who had more advanced disease at the time of their procedure.

CONCLUSION

The BUCMXE system allowed for objective quantification of radiographic changes following joint-preserving hip surgery in our cohort. Statistical analysis of BUCMXE scores demonstrated that the scoring system was sensitive to detect subtle radiographic changes associated with disease progression in the follow-up period.

LEVEL OF EVIDENCE

Therapeutic Level III.

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.

Endoscopic observation finding in the core decompression procedure of osteonecrosis of femoral head and effect of additional treatments

PURPOSE

To observe necrotic findings of the femoral head through the endoscopic examination when performing the decompression procedure widely used in the treatment of osteonecrosis of femoral head. To assess the efficacy of injection of bone marrow aspirated from the iliac crest and new vascularized bone graft into the core of femoral head based on the endoscopic findings.

METHODS

The first stage of osteonecrosis of femoral head based on ARCO classification includes 23, second stage 36, and third stage eight femoral heads. Bone marrow transplantations have been performed in 49 hip joints and new vascularized bone grafts in 18 hip joints.

RESULTS

The endoscopic findings of osteonecrosis of femoral heads are varied, and they can be divided into five categories. The average time in core decompression and bone marrow injection was 15 minutes, and the average time of new pedicled bone grafts was 65 minutes (45-90 minutes). The efficacy of bone marrow injection was 93.88%, and the efficacy of vascularized bone graft was 94.44% when performed based on the endoscopic findings.

CONCLUSION

It is possible to increase the treatment efficacy of the osteonecrosis of the femoral head when appropriate additional treatments are applied based on endoscopic findings in the decompression procedures of pre-collapse osteonecrosis of the femoral head.

Management of osteonecrosis of the femoral head

Aims

Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques.

Methods

A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated.

Results

The rate of joint-preserving procedures was significantly higher in patients aged < 50 years compared with those aged > 50 years (4.93% vs 1.52%; p < 0.001). For the overall cohort, rates of arthroplasty were far greater than those for joint-preserving procedures. THA was the most commonly performed procedure (291,114; 94.03%), while osteotomy (3,598; 1.16%), partial arthroplasty (9,171; 2.96%), core decompression (1,200; 0.39%), and bone graft (3,026; 0.98%) were performed markedly less frequently. The annual percentage of patients managed using a THA (93.56% to 89.52%; p < 0.001), resurfacing (1.22% to 0.19%; p < 0.001), and osteotomy (1.31% to 1.05%; p < 0.001) also decreased during the study period.

Conclusion

We found that patients with ONFH have been most commonly managed with non-joint-preserving procedures. Our findings provide valuable insight into the current management of this condition and should increase efforts being made to save the hip joint. Cite this article: Bone Joint J 2020;102-B(7 Supple B):122–128.

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.

Platelet-Rich Plasma-Incorporated Autologous Granular Bone Grafts Improve Outcomes of Post-Traumatic Osteonecrosis of the Femoral Head

BACKGROUND

To investigate the effects of platelet-rich plasma (PRP)-incorporated autologous granular bone grafts for treatment in the precollapse stages (Association of Research Circulation Osseous stage II-III) of posttraumatic osteonecrosis of the femoral head.

METHODS

A total of 46 patients were eligible and enrolled in the study. Twenty-four patients were treated with core decompression and PRP-incorporated autologous granular bone grafting (treatment group), and 22 patients were treated with core decompression and autologous granular bone grafting (control group). During a minimum follow-up duration of 36 months, X-ray and computed tomography were used to evaluate the radiological results, and the Harris hip score (HHS) and visual analog scale were chosen to assess the clinical results.

RESULTS

Both the treatment and control groups had a significantly improved HHS (P < .001). The minimum clinically important difference for the HHS was reached in 91.7% of the treatment group and 68.2% of the control group (P < .05). The HHS and visual analog scale in the treatment group were significantly improved than that in the control group at the last follow-up (P < .05). Successful clinical and radiological results were achieved 87.5% and 79.2% in the treatment group compared with 59.1% and 50.0% in the control group (P < .05), respectively. The survival rates based on the requirement for further hip surgery as an endpoint were higher in the treatment group in comparison to those in the control group (P < .05).

CONCLUSION

PRP-incorporated autologous granular bone grafting is a safe and effective procedure for treatment in the precollapse stages (Association of Research Circulation Osseous stage II-III) of posttraumatic osteonecrosis of the femoral head.

Bone-strengthening supplement (BSP) promotes bone and cartilage repair, for the treatment of Osteonecrosis of Femoral Head: an MRI-based study

Currently, no effective drug treatment is available for bone and joint disease, a disorder of the bone and cartilage cells. Osteonecrosis of the femoral head (ONFH) is an example of bone and joint disease. It is progressive, with femoral head collapse resulting from the death of osteocytes and the bone marrow, leading to a poor quality of life and surgical interventions. However, the mechanism of this disease is still unknown, and the effects of current therapy are not satisfactory. In our previous study, we showed, using an ONFH rat model, that a new Chinese medicine, "bone-strengthening supplement" (BSP), enhances bone growth, promotes bone density, and restores blood circulation in the femoral head, and can significantly relieve pain, improve hip joint function, and reduce claudication. In the present study, we evaluated the curative effect of BSP in patients with ONFH using MRI with a double-blind randomized protocol. BSP significantly relieved pain unlike the control treatment; in addition, this treatment could improve MRI signal in ONFH patients. These results suggest that, overall; BSP can restore blood circulation and promote bone and cartilage growth during restoration of bone necrosis and the treatment of bone and joint disease.