Skip to main content

Advertisement

SpringerLink
Log in

Treatment of Pre-Collapse Stages of Osteonecrosis of the Femoral Head: a Systematic Review of Randomized Control Trials

  • Review Article
  • Published:
HSS Journal ®

Abstract

Background

Treatment for osteonecrosis of the femoral head (ONFH) remains controversial. Current reviews include low-level evidence studies evaluating the treatment of both pre-collapse and collapse stages of the disease.

Questions/Purposes

The purpose of the current study is to systematically review the literature evaluating core decompression (CD) with bone marrow mesenchymal cells (BMMCs), CD alone, and bisphosphonate treatment in pre-collapse ONFH by focusing just on randomized clinical trials (RCTs) reporting functional and radiologic outcomes. We aim to determine if the literature provides evidence supporting any single approach.

Methods

Using PubMed and EMBASE databases, we reviewed the clinical evidence of treatments for pre-collapse ONFH following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve RCTs met the inclusion criteria.

Results

Results showed that CD with BMMCs has lower risk of femoral head collapse when compared to the CD alone excluding hips lost to follow-up (relative risk (RR) [95% CI]:0.25 [0.11, 0.60]; p = 0.002) and when assumed that hips lost to follow-up experienced collapse (RR [95% CI]: 0.11 [0.03, 0.47]; p = 0.003). Neither CD nor bisphosphonate treatments showed lower risk to femoral head collapse when compared to control treatments (p = 0.46 and 0.31, respectively)

Conclusion

Current literature shows that there is a lower risk of femoral head collapse in patients with ONFH treated with CD combined with BMMCs when compared to CD alone; however, there is no robust evidence to determine the effect on functional outcomes. More RCTs assessing new combination therapies and using standardized outcome measures are required.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

References

  1. Agarwala S, Shah S, Joshi VR. The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years. J Bone Joint Surg Br. 2009; 91: 1013-1018.

    Article  CAS  PubMed  Google Scholar 

  2. Agarwala S, Shah SB. Ten-year follow-up of avascular necrosis of femoral head treated with alendronate for 3 years. J Arthroplasty. 2011; 26: 1128-1134.

    Article  PubMed  Google Scholar 

  3. Agarwala S, Sule A, Pai BU, et al. Study of alendronate in avascular necrosis of bone. J Assoc Physicians India. 2001; 49: 949-950.

    CAS  PubMed  Google Scholar 

  4. Agarwala S, Sule A, Pai BU, et al. Alendronate in the treatment of avascular necrosis of the hip. Rheumatology (Oxford). 2002; 41: 346-347.

    Article  CAS  Google Scholar 

  5. Aldridge JM 3rd, Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique. J. bone Jt. surgery. American Vol. 2004;86-A Suppl:87–101.

  6. Anon. ARCO Committee on Terminology and Staging. The ARCO perspective for reaching one uniform staging system of osteonecrosis. In: Schoutens A, Arlet J, Gardeniers JWM, Huges SPF, editors. Bone circulation and vascularization in normal and pathological . Plenum Press. 1993:375–80.

  7. Arlet JFRP. Forage-biopsie de la tete femorale dans l’osteonecrose primitive. Observations histopathologiques portant sur huit foranes. Rev Rhum. 1964; 31: 257-64.

    Google Scholar 

  8. Cardozo JB, Andrade DMS, Santiago MB. The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clin Rheumatol. 2008; 27: 685-688.

    Article  PubMed  Google Scholar 

  9. Chen CH, Chang JK, Lai KA, et al. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: A two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 2012; 64: 1572-1578.

    Article  CAS  PubMed  Google Scholar 

  10. Cui Q, Botchwey EA. Emerging ideas: treatment of precollapse osteonecrosis using stem cells and growth factors. Clin Orthop Relat Res. 2011; 469: 2665-2669.

    Article  PubMed  Google Scholar 

  11. Gangji V, De Maertelaer V, Hauzeur J-P. Autologous bone marrow cell implantation in the treatment of non-traumatic osteonecrosis of the femoral head: Five year follow-up of a prospective controlled study. Bone. 2011;49:1005–1009. Available at: doi:10.1016/j.bone.2011.07.032

  12. Giusti A, Hamdy N a T, Dekkers OM, Ramautar SR, Dijkstra S, Papapoulos SE. Atypical fractures and bisphosphonate therapy: A cohort study of patients with femoral fracture with radiographic adjudication of fracture site and features. Bone. 2011;48:966–971. Available at: doi:10.1016/j.bone.2010.12.033

  13. Ha Y-C, Jung WH, Kim J-R, et al. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am. 2006; 88(Suppl 3): 35-40.

    Article  PubMed  Google Scholar 

  14. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res. 2002; 405: 14-23.

    Article  PubMed  Google Scholar 

  15. Hernigou P, Manicom O, Poignard A. Core decompression with marrow stem cells. Oper Tech Orthop. 2004; 14: 68.

    Article  Google Scholar 

  16. Hernigou P, Poignard A, Manicom O, et al. The use of percutaneous autologous bone marrow transplantation in nonunion and avascular necrosis of bone. J Bone Joint Surq Br. 2005; 87: 896-902.

    Article  CAS  Google Scholar 

  17. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: d5928.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Hsu SL, Wang CJ, Lee MS, et al. Cocktail therapy for femoral head necrosis of the hip. Arch Orthop Trauma Surg. 2010; 130: 23-29.

    Article  PubMed  Google Scholar 

  19. Hungerford DS, Jones LC. Asymptomatic osteonecrosis: should it be treated? Clin Orthop Relat Res. 2004; 429: 124-130.

    Article  PubMed  Google Scholar 

  20. Joaquin JMM-A, Ariana G, Jordan C V, Amelia N, Lane, Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. Current concepts on osteonecrosis of the femoral head. World J. Orthop. 2015;6:590. Available at: http://www.wjgnet.com/2218-5836/full/v6/i8/590.htm

  21. Johnson AJ, Mont MA, Tsao AK, et al. Treatment of femoral head osteonecrosis in the United States: 16-year analysis of the Nationwide Inpatient Sample. Clin Orthop Relat Res. 2014; 472: 617-623.

    Article  PubMed  Google Scholar 

  22. Jones JPJ. Fat embolism and osteonecrosis. Orthop Clin North Am. 1985; 16: 595-633.

    PubMed  Google Scholar 

  23. Kang P, Pei F, Shen B, et al. Are the results of multiple drilling and alendronate for osteonecrosis of the femoral head better than those of multiple drilling? A pilot study. Joint Bone Spine. 2012; 79: 67-72.

    Article  PubMed  Google Scholar 

  24. Koo KH, Kim R, Ko GH, et al. Preventing collapse in early osteonecrosis of the femoral head. A randomised clinical trial of core decompression. J Bone Joint Surq Br. 1995; 77: 870-874.

    CAS  Google Scholar 

  25. Koo KH, Kim R. Quantifying the extent of osteonecrosis of the femoral head. A new method using MRI. J Bone Joint Surg Br. 1995; 77: 875-880.

    CAS  PubMed  Google Scholar 

  26. Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surq Am. 2005; 87: 2155-2159.

    Article  Google Scholar 

  27. Lee YK, Ha YC, Cho YJ, et al. Does Zoledronate Prevent Femoral Head Collapse from Osteonecrosis? A Prospective, Randomized, Open-Label, Multicenter Study. J Bone Joint Surq Am. 2015; 97: 1142-1148.

    Article  Google Scholar 

  28. Li X, Xu X, Wu W. Comparison of bone marrow mesenchymal stem cells and core decompression in treatment of osteonecrosis of the femoral head : a meta-analysis. 2014;7:5024–5030.

  29. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009; 62: e1-34.

    Article  PubMed  Google Scholar 

  30. Ma M, Jj C, Rj S, Lc J, Jr L. Nontraumatic Osteonecrosis of the Femoral Head : Where Do We Stand Today ? 2015:1604–1627.

  31. Min BW, Song KS, Cho CH, et al. Untreated asymptomatic hips in patients with osteonecrosis of the femoral head. Clin Orthop Relat Res. 2008; 466: 1087-1092.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Mitchell DG, Rao VM, Dalinka MK, et al. Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings. Radiology. 1987; 162: 709-715.

    Article  CAS  PubMed  Google Scholar 

  33. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010; 8: 336-341.

    Article  PubMed  Google Scholar 

  34. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin. Orthop. Relat. Res. 1996:169–178

  35. Mont MA, Marulanda GA, Jones LC, et al. Systematic analysis of classification systems for osteonecrosis of the femoral head. J Bone Joint Surq Am. 2006; 88(Suppl 3): 16-26.

    Article  Google Scholar 

  36. Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am. 2010; 92: 2165-2170.

    Article  PubMed  Google Scholar 

  37. Mwale F, Wang H, Johnson AJ, et al. Abnormal vascular endothelial growth factor expression in mesenchymal stem cells from both osteonecrotic and osteoarthritic hips. Bull NYU Hosp Jt Dis. 2011; 69(Suppl 1): S56-61.

    PubMed  Google Scholar 

  38. Neumayr LD, Aguilar C, Earles AN, et al. Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment. J Bone Joint Surq Am. 2006; 88: 2573-2582.

    Article  Google Scholar 

  39. Nishii T, Sugano N, Miki H, et al. Does alendronate prevent collapse in osteonecrosis of the femoral head? Clin Orthop Relat Res. 2006; 443: 273-279.

    Article  PubMed  Google Scholar 

  40. Papakostidis C, Tosounidis TH, Jones E, Peter V. The role of “cell therapy” in osteonecrosis of the femoral head The role of “cell therapy” in osteonecrosis of the femoral head A systematic review of the literature and meta-analysis of 7 studies. 2016;3674.

  41. Parmar MK, Torri V, Stewart L. Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints. Stat Med. 1998; 17: 2815-2834.

    Article  CAS  PubMed  Google Scholar 

  42. Phemister DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surq Am. 1949; 31A: 55-66.

    CAS  Google Scholar 

  43. Pinggera. K KWSNAO. Interthrocanteric osteotomy for avascular necrosis of the head of the femur. Survival probability of two different methods. J Bone Jt. Surg Br. 84(6):817–24.

  44. Reis ND, Schwartz O, Militianu D, et al. Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head. J Bone Joint Surq Br. 2003; 85: 371-375.

    Article  CAS  Google Scholar 

  45. Sen RK, Tripathy SK, Aggarwal S, Marwaha N, Sharma RR, Khandelwal N. Early Results of Core Decompression and Autologous Bone Marrow Mononuclear Cells Instillation in Femoral Head Osteonecrosis. A Randomized Control Study. J. Arthroplasty. 2012;27:679–686. Available at: doi:10.1016/j.arth.2011.08.008

  46. Soohoo NF, Vyas S, Manunga J, et al. Cost-effectiveness analysis of core decompression. J Arthroplasty. 2006; 21: 670-681.

    Article  PubMed  Google Scholar 

  47. Steinberg ME, Larcom PG, Strafford B, Hosick WB, Corces A, Bands RE, Hartman KE. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin. Orthop. Relat. Res. 2001:71–78.

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

    Google Scholar 

  49. Stulberg BN, Davis a W, Bauer TW, et al. Osteonecrosis of the femoral head: A prospective randomized treatment protocol. Clin Orthop Relat Res. 1991; 268: 140-151.

    PubMed  Google Scholar 

  50. Wang C, Peng J, Lu S. Summary of the various treatments for osteonecrosis of the femoral head by mechanism: A review. Exp Ther Med. 2014; 8: 700-706.

    CAS  PubMed  PubMed Central  Google Scholar 

  51. Wang CJ, Wang FS, Yang KD, et al. Treatment of osteonecrosis of the hip: Comparison of extracorporeal shockwave with shockwave and alendronate. Arch Orthop Trauma Surg. 2008; 128: 901-908.

    Article  CAS  PubMed  Google Scholar 

  52. Zalavras CG, Lieberman JR. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg. 2014; 22: 455-464.

    Article  PubMed  Google Scholar 

  53. Zhao D, Cui D, Wang B, Tian F, Guo L, Yang L, Liu B, Yu X. Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells. Bone. 2012;50:325–330. Available at: doi:10.1016/j.bone.2011.11.002

  54. Zhao D, Cui D, Wang B, et al. Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells. Bone. 2012; 50: 325-330.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Jordan C. Villa MD, Jelle P. van der List MD, Arianna Gianakos DO & Joseph M. Lane MD

  2. Weill Cornell Medical College, New York, NY, 10065, USA

    Solomon Husain BS

Authors
  1. Jordan C. Villa MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Solomon Husain BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jelle P. van der List MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Arianna Gianakos DO
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joseph M. Lane MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jordan C. Villa MD.

Ethics declarations

Conflict of Interest

Jordan C. Villa, MD, Solomon Husain, BS, Jelle P. van der List, MD, Arianna Gianakos, DO, have declared that they have no conflict of interest. Joseph M. Lane, MD, reports other from Agnovos, Amgen, Bone Therapeutics, SA, Merck, Inc. CollPlant, Inc., Graftys, Kuros, and Lilly, Inc., outside the work.

Human/Animal Rights

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed Consent

N/A

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(PDF 1224 kb)

ESM 2

(PDF 1224 kb)

ESM 3

(PDF 1224 kb)

ESM 4

(PDF 1225 kb)

ESM 5

(PDF 1224 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Villa, J.C., Husain, S., van der List, J.P. et al. Treatment of Pre-Collapse Stages of Osteonecrosis of the Femoral Head: a Systematic Review of Randomized Control Trials. HSS Jrnl 12, 261–271 (2016). https://doi.org/10.1007/s11420-016-9505-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11420-016-9505-9

Keywords

Search

Navigation