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Do modern techniques improve core decompression outcomes for hip osteonecrosis?

ABSTRACT: Core decompression procedures have been used in osteonecrosis of the femoral head to attempt to delay the joint destruction that may necessitate hip arthroplasty. The efficacy of core decompressions has been variable with many variations of technique described. To determine whether the efficacy of this procedure has improved during the last 15 years using modern techniques, we compared recently reported radiographic and clinical success rates to results of surgeries performed before 1992. Additionally, we evaluated the outcomes of our cohort of 52 patients (79 hips) who were treated with multiple small-diameter drillings. There was a decrease in the proportion of patients undergoing additional surgeries and an increase in radiographic success when comparing pre-1992 results to patients treated in the last 15 years. However, there were fewer Stage III hips in the more recent reports, suggesting that patient selection was an important reason for this improvement. The results of the small-diameter drilling cohort were similar to other recent reports. Patients who had small lesions and were Ficat Stage I had the best results with 79% showing no radiographic progression. Our study confirms core decompression is a safe and effective procedure for treating early stage femoral head osteonecrosis.

SUBMITTER: Marker DR

PROVIDER: S-EPMC2311489 | biostudies-other | 2008 May

REPOSITORIES: biostudies-other

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Project description:IntroductionOsteonecrosis of the femoral head (ONFH) is a devastating disease with complete collapse of the femoral head often reported in greater than 70% of patients within 3 to 4 years of diagnosis. Early intervention prior to collapse may improve the chance of success of joint preserving procedures.Questions/purposesThe purpose of this study was to evaluate whether core decompression with mesenchymal stem cells combined with bisphosphonate therapy can improve the clinical outcomes and reduce the risk of hip replacement when compared to treatment with bisphosphonate therapy alone.MethodsBetween 2006 and 2014, 84 consecutive patients who were diagnosed with ONFH were identified from our institution's registry. Of these 84 patients, 49 patients (62 hips), fit inclusion/exclusion criteria. Twenty-nine patients (40 hips) were treated with bisphosphonate therapy only. Twenty patients (20 hips) were treated with bisphosphonates, core decompression, and mesenchymal stem cells. Functional outcomes were assessed using the Modified Harris Hip Score (MHHS), the visual analog score (VAS), and evaluation of support system. Clinical failure was defined as deterioration of the MHHS/VAS scores and support system used severe enough to require THR. Radiologic outcome measures included the XR and MR imaging staging of the hip. Survival analysis was performed with total hip replacement as the end point failure. Collapse was defined as progression from Ficat stage I or II to stage III and from Steinberg I, II, III to IV, V, VI.ResultsFailure requiring THR occurred in 21/40 (52.5%) of bisphosphonates (BP)-treated hips at a mean follow-up of 25.3 ± 11.5 months and 5/22 (22.73%) of BP + CD + MSC-treated hips at a mean follow-up of 22.7 ± 19.5 months. The median (Q1, Q3) time to collapse was 24.9 (7.4, 33.0) months in BP-treated hips and 27.3 (27.3) months in BP + CD + MSC-treated hips. There was no evidence of a difference in functional outcomes between the two treatment groups. After adjusting for baseline Ficat stage, age, and sex, an unreplaced hip treated with BP + CD + MSC had 0.42 (95% CI 0.11, 1.57) times the risk of being replaced in the next moment compared to an unreplaced hip treated with bisphosphonates only (P = 0.196).ConclusionOur results demonstrate that treatment with BP alone or BP + CD + MSC can postpone the need for total hip arthroplasty (THA) in the first 24 months in patients with ONFH compared to previously reported data, but there is no statistically significant difference between the two treatment groups. Combination therapy of BP + CD + MSC may be more effective in delaying the progression of collapse in early stage ONFH. Future prospective studies are warranted to determine the efficacy of these treatment strategies in the long term.

Project description:BackgroundVarious Joint-preserving therapy (JPT) methods have been performed and tried in recent decades, but their results and efficacy were inconsistent and controversial. The purpose of this study is to evaluate its effectiveness and whether there are statistical differences in treatment between different interventions based on published RCT studies.MethodsFollowing the PRISMA-NMA checklist, Medline, EMBASE, Web of Science, and Cochrane Library databases were searched and collected related RCT studies. The sources were searched from inception up to October 30, 2020. The primary outcomes including the rate of radiographic progression and conversion to THA and the secondary outcome -Harris Hip Scores (HHS) were extracted and compared in a Network meta-analysis.ResultsSeventeen RCT studies involving 784 patients (918 hips) with seven interventions including CD (core decompression), CD + BG (bone graft), CD + TI (tantalum rod implantation), CD + CT (Cell therapy), CD + BG + CT, VBG (vascularized bone graft), and nonsurgical or conservative treatment for ONFH were evaluated. In the radiographic progression results, CD + CT showed a relatively better result than CD, CD + BG and non-surgical treatment, the surface under the cumulative ranking curve (SUCRA) plot displayed that CD + CT (96.4%) was the best, followed by CD (64.1%).In conversion to THA results, there were no significant differences between the JPT methods and non-surgical treatment. In HHS, there was also no significant difference, other than CD + BG showed a statistical difference than non-surgical treatment only in terms of Cis, but the SUCRA was highest in non-surgical treatment (80.5%) followed by CD + CT (72.8%).ConclusionsThis Net-work meta-analysis demonstrated that there was no statistical difference in the outcome of radiographic progression and conversion to THA, also in HHS, other than CD + CT showed a relatively superior result in radiographic progression than nonsurgical treatment, namely, it's maybe an effective method for delaying disease progression or reducing disease development based on current evidence.

Project description:BACKGROUND: To investigate the efficacy of the sole core decompression surgery for the treatment of steroid-induced femoral head osteonecrosis. METHODS: The model was established by administration of steroids in combination with horse serum. The rabbits with bilateral femoral head osteonecrosis were randomly selected to do the one side of core decompression. The other side was used as the sham. Quantitative RT-PCR and western blot techniques were used to measure the local expression of BMP-2 and PPAR-?. Bone tissues from control and operation groups were histologically analyzed by H&E staining. The comparisons of the local expression of BMP-2 and PPAR-? and the bone regeneration were further analyzed between different groups at each time point. RESULTS: The expression of BMP-2 in the osteonecrosis femoral head with or without decompression was significantly lower than that in normal animals. BMP-2 expression both showed the decreasing trend with the increased post-operation time. No significant difference of BMP-2 expression occurred between femoral head osteonecrosis with and without decompression. The PPAR-? expression in the femoral head osteonecrosis with and without core decompression both was significantly higher than that in control. Its expression pattern showed a significantly increased trend with increased the post-operation time. However, there was no significant difference of PPAR-? expression between the femoral head osteonecrosis with and without decompression at each time point. Histopathological analysis revealed that new trabecular bone and a large number of osteoblasts were observed in the steroid-induced femoral head osteonecrosis with lateral decompression at 8?weeks after surgery, but there still existed trabecular bone fractures and bone necrosis. CONCLUSIONS: Although decompression takes partial effect in promoting bone regeneration in the early treatment of femoral head osteonecrosis, such an effect does not significantly improve or reverse the pathological changes of femoral head necrosis. Thus, the long-term effect of core decompression in the treatment of steroid-induced femoral head osteonecrosis is not satisfactory.

Project description:ObjectiveTo investigate the efficacy and safety of core decompression (CD) with local administration of zoledronate and enriched bone marrow mononuclear cells (BMMCS) for the treatment of non-traumatic osteonecrosis of femoral head (ONFH).MethodsA total of 17 patients (30 hips) diagnosed with stage II and III ONFH according to the 2019 revised Association for Research on Osseous Circulation (ARCO) staging criteria from 2012 to 2014 were retrospectively reviewed. The patients received the following therapy: the BMMCs and zoledronate were injected into the necrotic zone, respectively, along with CD. The mean age of the patients was 36.8 years; 14 were men and three were women. All patients included had non-traumatic ONFH and a minimum follow-up of 5 years, which ended when total hip arthroplasty (THA) was performed. Imaging modalities, including plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) were taken pre- and postoperatively. Harris hip score (HHS) was used to evaluate the functional outcomes of femoral head necrosis. Kaplan-Meier analysis was adopted to determine the probability of survivorship with THA as the end point in this series of patients. The correlation between radiological progression or THA and related risk factors were further analyzed. All complications were recorded.ResultsWith THA as the follow-up endpoint, All patients were followed up for an average of 69.1 ± 20.5 months (range, 18-95 months). Preoperative imaging found six hips (20%) at ARCO stage II, 14 hips (46.7%) at stage IIIA, 10 hips (33.3%) at stage IIIB. Fourteen hips (46.7%) shown progression radiologically, while six hips (20%) underwent TKA among these patients with hip preservation. The cumulative survival was 80% (95% CI, 0.608-905) at 5 years with THA as the end point. HHS improved from 63.3 ± 8.7 preoperatively to 74.6 ± 20.6 postoperatively (P = 0.000). Radiological progression was found to be associated with ARCO stage, Japanese Investigation Committee (JIC) type, and corticosteroid exposure (P = 0.047; P = 0.012; P = 0.031). However, no correlation was found between conversion to THA and the known risk factors. No major complication was reported, with only four patients complaining about general weakness and muscle soreness, and all disappeared within 2-3 days.ConclusionsThe novel treatment modality could relieve pain, delay the progression of collapse, which might be an effective and safe method for hip preservation of early and mid-term ONFH. However, the effect of this method may be related to ARCO stage, JIC type, and corticosteroid exposure.

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Do modern techniques improve core decompression outcomes for hip osteonecrosis?

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