Abstract
Avascular necrosis (AVN) of the femoral head is a debilitating disease of multifactorial genesis, predominately affects young patients, and often leads to the development of secondary osteoarthritis. The evolving field of regenerative medicine offers promising treatment strategies using cells, biomaterial scaffolds, and bioactive factors, which might improve clinical outcome. Early stages of AVN with preserved structural integrity of the subchondral plate are accessible to retrograde surgical procedures, such as core decompression to reduce the intraosseous pressure and to induce bone remodeling. The additive application of concentrated bone marrow aspirates, ex vivo expanded mesenchymal stem cells, and osteogenic or angiogenic growth factors (or both) holds great potential to improve bone regeneration. In contrast, advanced stages of AVN with collapsed subchondral bone require an osteochondral reconstruction to preserve the physiological joint function. Analogously to strategies for osteochondral reconstruction in the knee, anterograde surgical techniques, such as osteochondral transplantation (mosaicplasty), matrix-based autologous chondrocyte implantation, or the use of acellular scaffolds alone, might preserve joint function and reduce the need for hip replacement. This review summarizes recent experimental accomplishments and initial clinical findings in the field of regenerative medicine which apply cells, growth factors, and matrices to address the clinical problem of AVN.
Highlights
Osteonecrosis or avascular necrosis (AVN) is defined as a pathologic process that results from a critical reduction of blood supply to the bone and elevated intraosseous pressure
Joint-preserving techniques such as core decompression, avascular or vascularized bone grafting, and various femoral osteotomies are most promising in early stages of AVN – Association Research Circulation Osseous (ARCO) stage I and II – with preserved structural integrity of the subchondral plate [2]
Kawate and colleagues [18] reported the treatment of three patients with advanced stages of cortisone-induced AVN (Steinberg stage III or IV) with a vascularized fibular graft combined with a synthetic beta-tricalcium phosphate (β-TCP) ceramic and bone marrow-derived mesenchymal stem cell (MSC)
Summary
Osteonecrosis or avascular necrosis (AVN) is defined as a pathologic process that results from a critical reduction of blood supply to the bone and elevated intraosseous pressure. Kawate and colleagues [18] reported the treatment of three patients with advanced stages of cortisone-induced AVN (Steinberg stage III or IV) with a vascularized fibular graft combined with a synthetic β-TCP ceramic and bone marrow-derived MSCs. Four weeks prior to elective core decompression, 15 mL of bone marrow aspirate was taken from the iliac crest. Whereas control animals (core decompression only) showed AVN progression with structural disintegration and collapse of the subchondral bone 4 months after treatment, no signs of such progression were observed in the cell-treated groups [35]. An innovative one-step procedure combining microfracturing [52] of the subchondral bone and coverage of the cartilage defect by using an acellular scaffold (Autologous Matrix-Induced Chondrogenesis) was developed [53] Three patients have been treated with this technique with a follow-up of 9 months
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