Results of minimally invasive core decompression and autologous bone grafting in combination with autologous bone marrow aspirate concentrate in the treatment of patients with aseptic osteonecrosis of the femoral head

Introduction Currently, limb salvage methods have been used for the treatment of aseptic osteonecrosis of  the  femoral head (ANFH), but their use does not always avoid joint replacement in the later stages of the disease. The combination of core decompression and autologous bone grafting with autologous bone marrow aspirate concentrate (BMAC) in the treatment of patients with ANFH could improve their quality of life, delay joint replacement, or, in some cases, avoid it completely.

Purpose To evaluate the results of surgical treatment of patients with ANFH using minimally invasive core decompression and autologous bone grafting in combination with BMAC, develop an algorithm for choosing a method of surgical treatment based on the extent of damage to the femoral head and the stage of the disease.

Material and methods A pilot multicenter study included 86 patients diagnosed with ANFH. All patients underwent minimally invasive core decompression in combination with autologous bone grafting and BMAC. Results were analyzed 3, 6, 12 months after surgery.

Discussion Due to the fact that the presented study included mainly patients with post-Covid and steroidinduced osteonecrosis, and did not include patients with the first stage of the disease, the  percentage of positive treatment results was slightly lower compared to other similar studies.

Results Within 3 to 6 months after surgery, 21 patients (24 %) required joint replacement; among the remaining 65 patients (76 %), there was a significant improvement in the condition and quality of life that was confirmed by instrumental studies and functional assessment.

Conclusion The technique of minimally invasive core decompression and autologous bone grafting in combination with BMAC is an effective method of treatment patients with pre-collapse ANFH stages, might improve their quality of life but does not allow regression of structural changes in the bone.

1. Torgashin AN, Rodionova SS, Shumsky AA, et al. Treatment of aseptic necrosis of the femoral head. Clinical guidelines. Rheumatology Science and Practice. 2020;58(6):637-645. (In Russ.) doi: 10.47360/1995-4484-2020-637-645

2. Guggenbuhl P, Robin F, Cadiou S, Albert JD. Etiology of avascular osteonecrosis of the femoral head. Morphologie. 2021;105(349):80-84. doi: 10.1016/j.morpho.2020.12.002

3. Hines JT, Jo WL, Cui Q, et al. Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment. J Korean Med Sci. 2021;36(24):e177. doi: 10.3346/jkms.2021.36.e177

4. Lespasio MJ, Sodhi N, Mont MA. Osteonecrosis of the Hip: A Primer. Perm J. 2019;23:18-100. doi: 10.7812/TPP/18-100

5. George G, Lane JM. Osteonecrosis of the Femoral Head. J Am Acad Orthop Surg Glob Res Rev. 2022;6(5):e21.00176. doi: 10.5435/JAAOSGlobal-D-21-00176

6. Muthu S, Jeyaraman M, Selvaraj P, et al. Dose-Response Meta-Analysis of Corticosteroid Effects in SARS Outbreak: A Model for Risk Stratification and Screening Strategy for Osteonecrosis of Femoral Head Post-Corticosteroid Therapy for COVID-19. Life (Basel). 2023;13(4):907. doi: 10.3390/life13040907

7. Hassan AAA, Khalifa AA. Femoral head avascular necrosis in COVID-19 survivors: a systematic review. Rheumatol Int. 2023;43(9):1583-1595. doi: 10.1007/s00296-023-05373-8

8. Zhu D, Yu H, Liu P, et al. Calycosin modulates inflammation via suppressing TLR4/NF-κB pathway and promotes bone formation to ameliorate glucocorticoid-induced osteonecrosis of the femoral head in rat. Phytother Res. 2021;35(5):2824-2835. doi: 10.1002/ptr.7028

9. Motta F, Timilsina S, Gershwin ME, Selmi C. Steroid-induced osteonecrosis. J Transl Autoimmun. 2022;5:100168. doi: 10.1016/j.jtauto.2022.100168

10. Assouline-Dayan Y, Chang C, Greenspan A, et al. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 2002;32(2):94-124.

11. Tang C, Wang Y, Lv H, et al. Caution against corticosteroid-based COVID-19 treatment. Lancet. 2020;395(10239):17591760. doi: 10.1016/S0140-6736(20)30749-2

12. Velchov V, Georgiev P, Tserovski S, et al. Corticosteroid-Associated Avascular Necrosis of the Femoral Head in Patients with Severe COVID-19: A Single-Center Study. Med Sci Monit. 2023;29:e940965. doi: 10.12659/MSM.940965

13. Li W, Huang Z, Tan B, et al. General recommendation for assessment and management on the risk of glucocorticoidinduced osteonecrosis in patients with COVID-19. J Orthop Translat. 2021;31:1-9. doi: 10.1016/j.jot.2021.09.005

14. Mirzai R, Chang C, Greenspan A, Gershwin ME. The pathogenesis of osteonecrosis and the relationships to corticosteroids. J Asthma. 1999;36(1):77-95. doi: 10.3109/02770909909065152 15. Assouline-Dayan Y, Chang C, Greenspan A, et al. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 2002;32(2):94-124.

15. Chang C, Greenspan A, Gershwin ME. The pathogenesis, diagnosis and clinical manifestations of steroid-induced osteonecrosis. J Autoimmun. 2020;110:102460. doi: 10.1016/j.jaut.2020.102460

16. Powell C, Chang C, Gershwin ME. Current concepts on the pathogenesis and natural history of steroid-induced osteonecrosis. Clin Rev Allergy Immunol. 2011;41(1):102-13. doi: 10.1007/s12016-010-8217-z

17. Rosenwasser MP, Garino JP, Kiernan HA, Michelsen CB. Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis. Clin Orthop Relat Res. 1994;(306):17-27.

18. Arlet J, Ficat P, Lartigue G. Mode of onset of primary osteonecrosis of the femoral head. (Stage I. Uncomplicated). Study of 20 cases histologically verified by punch biopsy. Rev Rhum Mal Osteoartic. 1968;35(5):239-249.

19. Steinberg ME. Core decompression of the femoral head for avascular necrosis: indications and results. Can J Surg. 1995;38 Suppl 1:S18-24.

20. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;(324):169-178. doi: 10.1097/00003086-199603000-00020

21. Zhang C, Fang X, Huang Z, et al. Addition of Bone Marrow Stem Cells Therapy Achieves Better Clinical Outcomes and Lower Rates of Disease Progression Compared With Core Decompression Alone for Early Stage Osteonecrosis of the Femoral Head: A Systematic Review and Meta-Analysis. J Am Acad Orthop Surg. 2020;28(23):973-979. doi: 10.5435/JAAOS-D-19-00816

22. Hua KC, Yang XG, Feng JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res. 2019;14(1):306. doi: 10.1186/s13018-019-1359-7

23. Fang T, Zhang EW, Sailes FC, et al. Vascularized fibular grafts in patients with avascular necrosis of femoral head: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2013;133(1):1-10. doi: 10.1007/s00402-012-1627-z

24. Yu X, Zhang D, Chen X, et al. Effectiveness of various hip preservation treatments for non-traumatic osteonecrosis of the femoral head: A network meta-analysis of randomized controlled trials. J Orthop Sci. 2018;23(2):356-364. doi: 10.1016/j.jos.2017.12.004

25. Xu S, Zhang L, Jin H, et al. Autologous Stem Cells Combined Core Decompression for Treatment of Avascular Necrosis of the Femoral Head: A Systematic Meta-Analysis. Biomed Res Int. 2017;2017:6136205. doi: 10.1155/2017/6136205

26. Wang T, Wang W, Yin ZS. Treatment of osteonecrosis of the femoral head with thorough debridement, bone grafting and bone-marrow mononuclear cells implantation. Eur J Orthop Surg Traumatol. 2014;24(2):197-202. doi: 10.1007/s00590-012-1161-2

27. Lau RL, Perruccio AV, Evans HM, et al. Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014;15:156. doi: 10.1186/1471-2474-15-156

28. Jindal K, Aggarwal S, Kumar P, Rathod P. Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis. J Clin Orthop Trauma. 2021;17:78-87. doi: 10.1016/j.jcot.2021.02.010

29. Sadile F, Bernasconi A, Russo S, Maffulli N. Core decompression versus other joint preserving treatments for osteonecrosis of the femoral head: a meta-analysis. Br Med Bull. 2016;118(1):33-49. doi: 10.1093/bmb/ldw010

30. Van Laere C, Mulier M, Simon JP, et al. Core decompression for avascular necrosis of the femoral head. Acta Orthop Belg. 1998;64(3):269-272.

31. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;(324):169-178. doi: 10.1097/00003086-199603000-00020

32. Seyler TM, Marker DR, Ulrich SD, et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis. Clin Orthop Relat Res. 2008;466(5):1125-1132. doi: 10.1007/s11999-008-0211-x

33. Singh H, Agarwal KK, Tyagi S, et al. An Evaluation of Core Decompression and Cancellous Bone Grafting for EarlyStage Avascular Necrosis of the Femoral Head. Cureus. 2023;15(4):e37878. doi: 10.7759/cureus.37878

34. Ma Y, Wang T, Liao J, et al. Efficacy of autologous bone marrow buffy coat grafting combined with core decompression in patients with avascular necrosis of femoral head: a prospective, double-blinded, randomized, controlled study. Stem Cell Res Ther. 2014;5(5):115. doi: 10.1186/scrt505

35. Zhang C, Fang X, Huang Z, et al. Addition of Bone Marrow Stem Cells Therapy Achieves Better Clinical Outcomes and Lower Rates of Disease Progression Compared With Core Decompression Alone for Early Stage Osteonecrosis of the Femoral Head: A Systematic Review and Meta-Analysis. J Am Acad Orthop Surg. 2020;28(23):973-979. doi: 10.5435/JAAOS-D-19-00816

36. Oryan A, Kamali A, Moshiri A, et al. Role of Mesenchymal Stem Cells in Bone Regenerative Medicine: What Is the Evidence? Cells Tissues Organs. 2017;204(2):59-83. doi: 10.1159/000469704

37. Hernigou P, Poignard A, Zilber S, Rouard H. Cell therapy of hip osteonecrosis with autologous bone marrow grafting. Indian J Orthop. 2009;43(1):40-45. doi: 10.4103/0019-5413.45322

38. Kondrashenko VV, Malanin DA, Demeshchenko MV. Method for obtaining an autologous concentrate of bone marrow cells for the treatment of inflammatory and degenerative diseases in traumatology and orthopedics. Patent RF, no. 2763250, 2021. Available at: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&rn=7773&DocNumber=2763250&TypeFile=html. Accessed Oct 03, 2024. (In Russ.)

39. Strahov MA, Zagorodnij NV, Lazishvili GD et al. Features of the use of platelet-rich plasma (PRP) in traumatology, orthopedics and sports medicine. Opinion Leader. 2016;1(1):50-55. (In Russ.) URL: http://library.opinionleaderjournal.com/books/jwkh/#p=52

40. Perechodov SN, Bryzshan LK, Davydov DV, et al. The adoption tissue engineering in integrated treatment of gunshots fructures by long bones. Technologies of Living Systems. 2010;7(5):60-62. (In Russ.).