International Orthopaedics

, Volume 42, Issue 7, pp 1723–1728 | Cite as

Early-stage osteonecrosis of the femoral head: where are we and where are we going in year 2018?

  • Eric Larson
  • Lynne C. Jones
  • Stuart B. Goodman
  • Kyung-Hoi Koo
  • Quanjun Cui
Review Article


Osteonecrosis of the femoral head (ONFH) is a devastating condition affecting relatively young patients whereby the femoral head is necrotic, resulting in significant pain, articular surface collapse, and eventual osteoarthritis. This condition has been highly associated with chronic steroid use, alcoholism, and hip trauma, as well as other less common conditions. Without intervention, this condition has a high likelihood of progressing and developing into end-stage osteoarthritis. Unfortunately, ONFH is difficult to diagnose on plain radiographs in the early stages of the disease, and often requires more advanced imaging modalities such as MRI in order to fully assess for early degeneration. Providers, therefore, must have a high index of suspicion when a younger patient presents with hip pain and negative X-rays. Unfortunately, in patients whose femoral heads have already collapsed, joint-preserving procedures are not effective, and total hip arthroplasty remains the most reliable long-term treatment. Multiple treatments have been pursued to address osteonecrosis in patients whose femoral head have not yet collapsed, but the results of these treatments are mixed. The most promising of these interventions to date is core decompression with the use of concentrated bone marrow aspirate to improve the healing potential of the femoral head. Further studies including randomized clinical trials are necessary in order to assess the effectiveness of this therapy, the best possible source of cells and the best method of implantation in order to further improve results in those with pre-collapse ONFH.


Osteonecrosis Avascular necrosis Stem cells Mesenchymal stem cells Core decompression Femoral head Hip 


Compliance with ethical standards

Conflict of interest

Dr. Cui or an immediate family member serves as a paid consultant to Exactech has received research or institutional support from the National Institute of Health, Department of Defense and Exactech; serves as a board member, owner, officer, or committee member of the Virginia Orthopaedic Society, Journal of Arthroplasty, World Journal of Orthopaedics and Journal of Orthopaedic Research; and received royalties from Elsevier. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Larson, Dr. Goodman, Dr. Jones, and Dr. Koo.


  1. 1.
    Moya-Angeler J, Gianakos A, Villa J, Ni A, Lane J (2015) Current concepts on osteonecrosis of the femoral head. World J Orthop 6:590–601CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Papakostidis C, Tosounidis T, Jones E, Giannoudis P (2016) The role of “cell therapy” in osteonecrosis of the femoral head: a systematic review of the literature and meta-analysis of 7 studies. Acta Orthop 87:71–78CrossRefGoogle Scholar
  3. 3.
    Lau R, Perruccio A, Evan H, Mahomed S, Mahomed N, Gandhi R (2014) Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord 15:1–10CrossRefGoogle Scholar
  4. 4.
    Hernigou P, Trousselier M, Roubineau F, Bouthors C, Chevallier N, Rouard H, Flouzat-Lachaniette C (2016) Stem cell therapy for the treatment of hip osteonecrosis: a 30-year review of progress. Clin Orthop Surg 8:1–8CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Looney A, Dighe A, Novicoff W, Cui Q (2016) Stem cell therapy for early stage osteonecrosis: challenges and future research direction. Formosan J Musculoskelet Disord 7:119–126. Google Scholar
  6. 6.
    Wang C, Wand Y, Meng HY, Yuan XL, Xu XL, Wang AI, Guo QY, Peng J, Lu SB (2015) Application of bone marrow mesenchymal stem cells to the treatment of osteonecrosis of the femoral head. Int J Clin Exp Med 8:3127–3135PubMedPubMedCentralGoogle Scholar
  7. 7.
    Pepke W, Kasten P, Beckmann N, Janicki P, Egermann M (2016) Core decompression and autologous bone marrow concentrate for treatment of femoral head osteonecrosis: a randomized prospective study. Orthop Rev 8:5–9CrossRefGoogle Scholar
  8. 8.
    Kaushik A, Das A, Cui Q (2012) Osteonecrosis of the femoral head: an update in the year 2012. World J Orthop 3:49–56CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mont M, Cherian J, Sierra R, Jones L, Lieberman J (2015) Nontraumatic osteonecrosis of the femoral head: where do we stand today? J Bone Joint Surg Am 97:1604–1627CrossRefPubMedGoogle Scholar
  10. 10.
    Gardeniers J, Gosling-Gardeniers A, Rijnen W (2014) The ARCO staging system: generation and evolution since 1991. In: Koo KH, Mont M, Jones L (eds) Osteonecrosis. Springer, New York, pp 215–218Google Scholar
  11. 11.
    Xu S, Zhang L, Jin H, Shan L, Zhou L, Xiao L, Tong P (2017) Autologous stem cells combined core decompression for treatment of avascular necrosis of the femoral head: a systematic meta-analysis. Biomed Res Int 2017:1–11Google Scholar
  12. 12.
    Wang BL, Sun W, Shi ZC, Yue DB, Guo WS, Xu SQ, Lou JN, Li ZR (2010) Treatment of nontraumatic osteonecrosis of the femoral head with the implantation of core decompression and concentrated autologous bone marrow containing mononuclear cells. Arch Orthop Trauma Surg 130:859–865CrossRefPubMedGoogle Scholar
  13. 13.
    Tabatabaee R, Saberi S, Parvizi J, Mortazavi S, Farzan M (2015) Combining concentrated autologous bone marrow stem cells injection with core decompression improves outcome for patients with early-stage osteonecrosis of the femoral head: a comparative study. J Arthroplast 30(Suppl 1):11–15CrossRefGoogle Scholar
  14. 14.
    Houdek M, Wyles C, Packard B, Terzic A, Behfar A, Sierra R (2016) Decreased osteogenic activity of mesenchymal stem cells in patients with corticosteroid-induced osteonecrosis of the femoral head. J Arthroplast 31:893–898CrossRefGoogle Scholar
  15. 15.
    Hernigou P, Poignard A, Manicom O, Mathieu G, Rouard H (2005) The use of percutaneous autologous bone marrow transplantation in nonunion and avascular necrosis of bone. J Bone Joint Surg (Br) 87:896–902CrossRefGoogle Scholar
  16. 16.
    Yan Z, Hang D, Guo C, Chen Z (2009) Fate of mesenchymal stem cells transplanted to osteonecrosis of femoral head. J Orthop Res 27:442–446CrossRefPubMedGoogle Scholar
  17. 17.
    Ma Y, Wang T, Liao J, Gu H, Lin X, Jiang Q, Bulsara MK, Zheng M, Zheng Q (2014) 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 5:115CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Zhao D, Cui D, Wang B, Tian F, Guo L, Yang L, Liu B, Yu X (2012) Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells. Bone 50:325–330CrossRefPubMedGoogle Scholar
  19. 19.
    Sen RK, Tripathy SK, Aggarwal S, Marwaha N, Sharma RR, Khandelwal N (2012) Early results of core decompression and autologous bone marrow mononuclear cells instillation in femoral head osteonecrosis: a randomized control study. J Arthroplast 27:679–686CrossRefGoogle Scholar
  20. 20.
    Lim YW, Kim YS, Lee JW, Kwon SY (2013) Stem cell implantation for osteonecrosis of the femoral head. Exp Mol Med 45:e61. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Song H, Tao L, Wang F, Wand W, Wei Y, Shen W, Zhou F (2015) Effect of bone mesenchymal stem cells transplantation on the micro-environment of early osteonecrosis of the femoral head. Int J Clin Exp Pathol 8:14528–14534PubMedPubMedCentralGoogle Scholar
  22. 22.
    Yuan HF, Zhang J, Guo CG, Yan ZQ (2016) Clinical outcomes of osteonecrosis of the femoral head after autologous bone marrow stem cell implantation: a meta-analysis of seven case-control studies. Clinics 71:110–113CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Pak J, Lee J, Park K, Park M, Kang LW, Lee S (2017) Current use of autologous adipose tissue-derived stromal vascular fraction cells for orthopedic applications. J Biomed Sci 24:1–12CrossRefGoogle Scholar
  24. 24.
    Baer PC, Geiger H (2012) Adipose-derived mesenchymal stromal/stem cells: tissue localization, characterization, and heterogeneity. Stem Cells Int 2012:1–11CrossRefGoogle Scholar
  25. 25.
    Wyles C, Houdek M, Crespo-Diaz R, Norambuena G, Stalboerger P, Terzic A, Behfar A, Sierra R (2015) Adipose-derived mesenchymal stem cells are phenotypically superior for regeneration in the setting of osteonecrosis of the femoral head. Clin Orthop Relat Res 473:3080–3090CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Hernigou P, Beaujean F (1997) Abnormalities in the bone marrow of the iliac crest in patients who have osteonecrosis secondary to corticosteroid therapy or alcohol abuse. J Bone Joint Surg Am 79:1047–1053CrossRefPubMedGoogle Scholar
  27. 27.
    Cui Q, Wang GJ, Balian G (1997) Steroid-induced adipogenesis in a pluripotential cell line from bone marrow. J Bone Joint Surg Am 79:1054–1063CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryUniversity of Virginia School of MedicineCharlottesvilleUSA
  2. 2.Department of Orthopaedic SurgeryJohns Hopkins School of MedicineBaltimoreUSA
  3. 3.Department of Orthopaedic SurgeryStanford University Medical Center Outpatient CenterRedwood CityUSA
  4. 4.Department of Orthopedic SurgerySeoul National University, Bundang HospitalSeongnamSouth Korea

Personalised recommendations