Early Stage Avascular Necrosis Research Articles

Core decompression and biotechnologies in the treatment of avascular necrosis of the femoral head.

Avascular necrosis (AVN) of the femoral head (FH) causes 5% to 12% of total hip arthroplasties (THA). It especially affects active male adults between the third and fifth decades of life. The exact worldwide incidence is unknown. There are only few data related to each country, but most of it relates to the United States.Non-surgical management has a very limited role in the treatment of AVN of the FH and only in its earliest stages. Core decompression (CD) of the hip is the most common procedure used to treat the early stages of AVN of the FH. Recently, surgeons have considered combining CD with autologous bone-marrow cells, demineralised bone matrix or bone morphogenetic proteins or methods of angiogenic potential to enhance bone repair in the FH.Manuscripts were deemed eligible for our review if they evaluated treatment of early stage AVN of the FH with biotechnology implanted via CD. After application of eligibility criteria, we selected 19 reports for final analysis.The principal results showed that only by correctly mastering the therapeutic principles and adopting proper methods specifically oriented to different stages can the best therapeutic effect be achieved. Combining CD with biotechnology could result in a novel long-lasting hip- preserving treatment option.Furthermore, more refined clinical studies are needed to establish the effectiveness of biotechnology treatments in AVN of the FH.Cite this article: EFORT Open Rev 2017;2:41-50. DOI: 10.1302/2058-5241.2.150006

Role of hyperbaric oxygen therapy as a treatment for early stage of avascular necrosis of the femoral head in Indian army soldiers, a review of 10 cases

Role of hyperbaric oxygen therapy as a treatment for early stage of avascular necrosis of the femoral head in Indian army soldiers, a review of 10 cases

Effectiveness of Lower Energy Density Extracorporeal Shock Wave Therapy in the Early Stage of Avascular Necrosis of the Femoral Head.

ObjectiveTo evaluate the effectiveness of lower energy flux density (EFD) extracorporeal shock wave therapy (ESWT) in the early stage of avascular necrosis (AVN) of the femoral head.MethodsNineteen patients and 30 hips were enrolled. All subjects received 4 weekly sessions of ESWT, at different energy levels; group A (n=15; 1,000 shocks/session, EFD per shock 0.12 mJ/mm2) and group B (n=15; 1,000 shocks/session, EFD per shock 0.32 mJ/mm2). We measured pain by using the visual analog scale (VAS), and disability by using the Harris hip score, Hip dysfunction and Osteoarthritis Outcome Score (HOOS), and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). To determine the effect of the lower EFD ESWT, we assessed the VAS, Harris hip score, HOOS, WOMAC of the subjects before and at 1, 3, and 6 months.ResultsIn both groups, the VAS, Harris hip score, HOOS, and WOMAC scores improved over time (p<0.05).ConclusionLower EFD ESWT may be an effective method to improve the function and to relieve pain in the early stage of AVN.

MRI-guidance in percutaneous core decompression of osteonecrosis of the femoral head.

The purpose of this study was to evaluate the usefulness of MRI-guidance for core decompression of avascular necrosis of the femoral head. Twelve MRI-guided core decompressions were performed on patients with different stages of avascular necrosis of the femoral head. The patients were asked to evaluate their pain and their ability to function before and after the procedure and imaging findings were reviewed respectively. Technical success in reaching the target was 100 % without complications. Mean duration of the procedure itself was 54 min. All patients with ARCO stage 1 osteonecrosis experienced clinical benefit and pathological MRI findings were seen to diminish. Patients with more advanced disease gained less, if any, benefit and total hip arthroplasty was eventually performed on four patients. MRI-guidance seems technically feasible, accurate and safe for core decompression of avascular necrosis of the femoral head. Patients with early stage osteonecrosis may benefit from the procedure. • MRI is a useful guidance method for minimally invasive musculoskeletal interventions. • Bone drilling seems beneficial at early stages of avascular necrosis. • MRI-guidance is safe and accurate for bone drilling.

Is MRI Necessary for Skeletal Evaluation in Sickle Cell Disease.

More than 50% of the world's cases of sickle cell anaemia are in India with an estimated population of 1.27 billion as against estimated world's population of 7.24 billion. MRI of 103 patients of sickle cell disease were evaluated to assess the skeletal changes in proven cases of sickle cell disease and to find the incidence of bony infarcts in such patients. The conversion of red marrow to yellow marrow in these patients were also studied. Sickle cell patients with musculoskeletal pain as well as asymptomatic sickle cell patients were evaluated by MRI. The standard sequences used wereT1WI, T2WI, STIR, T1WI + Gd Contrast. Persistent Red marrow was seen in axial and appendicular skeleton (62 cases). Extramedullary haematopoiesis was found in 4 cases, avascular necrosis of femur head (32 cases) and bone infarcts (46 cases) were also observed in our study. Osteomyelitis, septic arthritis and tubercular infections were associated with sickle cell disease in our study. MRI is very sensitive in detecting early stages of avascular necrosis, red marrow persistence, extramedullary haematopoiesis, changes of arthritis, infections and joint effusion.

Surgical management of osteonecrosis of the femoral head in patients with sickle cell disease.

Sickle cell disease is a known risk factor for osteonecrosis of the hip. Necrosis within the femoral head may cause severe pain, functional limitations, and compromise quality of life in this patient population. Early stages of avascular necrosis of the hip may be managed surgically with core decompression with or without autologous bone grafting. Total hip arthroplasty is the mainstay of treatment of advanced stages of the disease in patients who have intractable pain and are medically fit to undergo the procedure. The management of hip pathology in sickle cell disease presents numerous medical and surgical challenges, and the careful perioperative management of patients is mandatory. Although there is an increased risk of medical and surgical complications in patients with sickle cell disease, total hip arthroplasty can provide substantial relief of pain and improvement of function in the appropriately selected patient.

Management of stage I and II A/B avascular necrosis of femoral head with core decompression autologous cancellous bone grafting and platelet rich plasma factors

Background: Avascular necrosis (AVN) of the femoral head is a progressive disease that generally affects patients in the third through fifth decades of life; if left untreated, it leads to complete deterioration of the hip joint. Treatments range from simple decompression of the femoral head, to bone grafting of the involved area, or by using a vascularized fibular graft with varying degree of success. In most instances, the disease progresses further causing secondary arthritis. We present a study of management of early stage AVN (stage I and II A/B of Ficat Arlet classification) with core decompression autologous cancellous bone grafting along with platelet rich plasma. Aims: To evaluate the results of the above modality in the management of AVN of the hip. Settings and Design: This prospective study of 30 cases was done during the period of 2011-2013. Materials and Methods: Patients with stage I and II A/B were treated with the above modality and were followed up for 1-year. The results were evaluated on the basis of progression or remission of the disease by radiographic studies, preoperative and postoperative Harris hip score (HHS), age and sex distribution. Statistical Analysis Used: Primer software for calculating the statistical data was used and paired t -test was applied to all the data. Results: Show males were more affected than females and average age group of presentation in stage I and II was 29 years (22-55). The most common cause was idiopathic followed by steroid use. Average preoperative HHS was 56.80 and postoperative HHS was 79.73. 60% (18) showed remission of the disease (radiographically) compared to preoperative stage at 1-year follow-up, in 30% (9) disease did not progress further and 10% (3) progressed and required arthroplasty. Conclusion: Management of stage I and II A/B AVN of femur showed good satisfactory results in terms of disease remission and prevention of the further progress of the disease by the above method at 1-year follow-up and further follow-up is awaited.

Effectiveness of synovial fluid mesenchymal stem cells embedded in alginate beads for treatment of steroid-induced avascular necrosis of the femoral head

ObjectiveTreatment of early stage avascular necrosis of the femoral head (AVNFH) is still challenging for clinicians today. Core decompression with the implantation of mesenchymal stem cells (MSCs) has become popular and been proven to be an effective therapy for ANNFH. Synovial fluid MSCs, which can be easily harvested by joint aspiration, reportedly have the potential to differentiate into bone and cartilage. The purpose of this investigation is to evaluate the effectiveness of core decompression plus the implantation of alginate beads embedded with synovial fluid MSCs (ABSMSCs) in bone regeneration in the treatment of steroid-induced AVNFH in a rabbit model. MethodsAn in vitro study is carried out to evaluate the bioactivity and osteogenic differentiation of synovial fluid MSCs in the environment formed by alginate beads. In an in vivo study, the application of ABSMSCs was combined with bone decompression to treat steroid-induced AVNFH in a rabbit model. Bone mineral density, radiography and histology were used to evaluate the bone growth of the femoral head after the rabbits had been euthanized 6 weeks after surgery. ResultsThe results obtained in vitro showed that the synovial fluid MSCs in the environment of alginate beads had the potential to differentiate toward bone growth. In vivo, the treatment of steroid-induced AVNFH in a rabbit model by core decompression plus the implantation of ABSMSCs preserved the bone density and sphericity of the femoral head and promoted bone regeneration. ConclusionImplantation of ABSMSCs is a novel and effective therapy for AVNFH. Hopefully, this application will improve the outcome of early stage AVNFH and facilitate the harvesting of stem cells.

Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review.

BackgroundAvascular necrosis (AVN) of the femoral head (FH) is believed to be caused by a multitude of etiologic factors and is associated with significant morbidity in younger populations. Eventually, the disease progresses and results in FH collapse. Thus, a focus on early disease management aimed at joint preservation by preventing or delaying progression is key. The use of stem cells (SC) for the treatment of AVN of the FH has been proposed. We undertook a systematic review of the medical literature examining the use of SC for the treatment of early stage (precollapse) AVN of the FH, in both pre-clinical and clinical studies.MethodsData collected included: Pre-clinical studies – model of AVN, variety and dosage of SC, histologic and imaging analyses. Clinical studies – study design, classification and etiology of AVN, SC dosage and treatment protocol, incidence of disease progression, patient reported outcomes, volume of necrotic lesion and hip survivorship.ResultsIn pre-clinical studies, the use of SC uniformly demonstrated improvements in osteogenesis and angiogenesis, yet source of implanted SC was variable. In clinical studies, groups treated with SC showed significant improvements in patient reported outcomes; however hip survivorship was not affected. Discrepancies regarding dose of SC, AVN etiology and disease severity were present.ConclusionsRoutine use of this treatment method will first require further research into dose and quality optimization as well as confirmed improvements in hip survivorship.

Intralesional autologous mesenchymal stem cells in management of osteonecrosis of femur: a preliminary study

Management of early stages of osteonecrosis aims to prevent the collapse of the femoral head by attempts at restoring the vascularity of femoral head. Bone marrow-derived mononuclear cells with their angiogenic and osteogenic properties appear to have the potential to halt the disease process when injected intralesionally following core decompression. Forty patients (60 hips) with stage I, II or III (ARCO system) osteonecrosis of femoral head were treated by either core decompression and isolated mononuclear cells (group A) or core decompression and unprocessed bone marrow injection (group B). The patients were followed up clinically and radiologically for a minimum of 2years. The functional outcome was assessed in terms of Harris hip score, and disease progression was assessed radiologically by comparing the preoperative and follow-up MRI at the end of 2years. On 2-year follow-up, there was considerable improvement in the hip function as measured by the Harris hip score in both the groups (p=0.031). On MRI, there was a decrease in the size of the lesion in group A (p=0.03). Three of 30 hips (10.0%) in group B required total hip replacement. Implantation of autologous bone marrow stem cells in avascular necrosis of femoral head is a safe and effective procedure and has better outcome than bone marrow for early stage of avascular necrosis of femoral head.

A tissue engineering strategy for the treatment of avascular necrosis of the femoral head

Background & purposeSkeletal stem cells (SSCs) and impaction bone grafting (IBG) can be combined to produce a mechanically stable living bone composite. This novel strategy has been translated to the treatment of avascular necrosis of the femoral head. Surgical technique, clinical follow-up and retrieval analysis data of this translational case series is presented. MethodsSSCs and milled allograft were impacted into necrotic bone in five femoral heads of four patients. Cell viability was confirmed by parallel in vitro culture of the cell-graft constructs. Patient follow-up was by serial clinical and radiological examination. Tissue engineered bone was retrieved from two retrieved femoral heads and was analysed by histology, microcomputed tomography (μCT) and mechanical testing. ResultsThree patients remain asymptomatic at 22- to 44-month follow-up. One patient (both hips) required total hip replacement due to widespread residual necrosis. Retrieved tissue engineered bone demonstrated a mature trabecular micro-architecture histologically and on μCT. Bone density and axial compression strength were comparable to trabecular bone. ConclusionsClinical follow-up shows this to be an effective new treatment for focal early stage avascular necrosis of the femoral head. Unique retrieval analysis of clinically translated tissue engineered bone has demonstrated regeneration of tissue that is both structurally and functionally analogous to normal trabecular bone.

Hyperbaric oxygen therapy in early stage avascular necrosis of femoral head

Hyperbaric oxygen therapy in early stage avascular necrosis of femoral head

Endoscopic and Arthroscopic Assistance in Femoral Head Core Decompression

Core decompression is a joint-preserving surgery feasible in early-stage avascular necrosis of the femoral head. An arthroscopically/endoscopically aided development of this procedure is presented to overcome some drawbacks of the standard technique. Conventional imaging may underestimate the articular damage; thus a preliminary hip arthroscopy helps to identify those patients with significant joint damage, who might not benefit from the procedure. The standard fluoroscopically guided core decompression does not allow precise targeting or reliable debridement of the lesion. Tunnel endoscopy helps the surgeon to aim precisely at the lesion and to debride it thoroughly, with accurate visual verification. In conclusion, the arthroscopic-endoscopic assistance may lead to more accurate patient selection, more precise targeting, and more complete debridement, with no apparent disadvantages.

EVALUATION OF DIFFERENT MODALITIES OF SURGICAL TREATMENT FOR AVASCULAR NECROSIS OF THE FEMORAL HEAD IN BASRAH

This prospective study was done in Basrah General Hospital, from June 2009 to December 2011. It included 92 hips in eighty one patients affected clinically and radiologically by femoral head avascular necrosis. They were 50 males and 31 females, mean age 41 years with a range of 15-67 years with stage II-IV of femoral head AVN according to Ficat and Arlet radiological staging system. The aims of this study are; to know the pattern of avascular necrosis of the femoral head, and to evaluate the outcome of the different surgical modalities. Surgery was conducted in form of; group I includes twenty four hips (24.4%) which were treated by core decompression (12 hips =12.2% by multiple small drilling (group I-a); seven patients were satisfied with the result of surgery. Infection was reported in one patient. Twelve hips =12.2% by wide bore drilling "gutter" and bone graft(group I-b); nine patients were satisfied by the result of surgery). Group II includes fifty three hips (54.1%) which were treated by total hip arthroplasty (25=25.5% cemented THR (group II-a); seventeen patients were satisfied with the procedure; Complications were reported in three cases, and 28=28.6% cementlessTHR (group II-b); twenty one patients were satisfied; complications had been encountered in five cases); five patients had bilateral hip surgery. Group III includes twenty one hips (21.4%) which were tackled by Girdlestone (resection arthroplasty); six patients had bilateral hip surgery. Only nine patients were satisfied with this procedure. In conclusion, core decompression surgery in form of wide bore drilling with bone graft is suitable treatment for early stages of avascular necrosis. Total hip replacement is suitable option for AVN in advance stage. Resection arthroplasty still is an option for patients in certain situations (e.g. infection), although the results were less favorable.

Change in hepatocyte growth factor concentration promote mesenchymal stem cell‐mediated osteogenic regeneration

Mesenchymal stem cells (MSCs) play a crucial role in tissue repair by secretion of tissue nutrient factors such as hepatocyte growth factor (HGF). However, studies examining the effects of HGF on the proliferation and differentiation of MSCs used different concentrations of HGF and reported conflicting conclusions. This study aimed to determine the mechanisms by which different concentrations of HGF regulate MSC proliferation and osteogenic differentiation, and validate the mechanism in an animal model of early stage avascular necrosis of femoral head (ANFH). Our results demonstrate that a low concentration of HGF (20 ng/ml) preferentially promotes MSC osteogenic differentiation through increased c-Met expression and phosphorylation, Akt pathway activation, and increased expression of p27, Runx2 and Osterix. In contrast, a high concentration of HGF (100 ng/ml) strongly induced proliferation by inducing strong activation of the ERK1/2 signalling pathway. As validated by animal experiments, high localized expression of HGF achieved by transplantation of HGF transgenic MSCs into ANFH rabbits increased the number of MSCs. Subsequently, 2 weeks after transplantation, HGF levels decreased and MSCs differentiated into osteoblasts and resulted in efficient tissue repair. Our results demonstrate that sequential concentration changes in HGF control the proliferation and osteogenic differentiation of MSCs in vivo. This phenomenon can be exploited therapeutically to induce bone regeneration and, in turn, improve the efficacy of pharmacological intervention for ANFH treatment.

Stem cell- and growth factor-based regenerative therapies for avascular necrosis of the femoral head

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.

Arthroscopic Core Decompression of the Lunate in Early Stage Kienbock Disease of the Lunate

Since the first description of Kienbock disease in 1910, the etiology and treatment have remained controversial topics. Core decompression is an accepted treatment option in early-stage avascular necrosis of the femoral head, and more recently the humeral head. This paper reports the technique of arthroscopic fluoroscopically guided core decompression of the lunate with 6-year results.

Mesenchymal stem cells cultured on tantalum used in early-stage avascular necrosis of the femoral head

Avascular necrosis of the femoral head (ANFH) is a common ailment characterized by necrosis of bone trabecular and bone marrow. It's mainly caused by the destruction of the blood supply in the femoral head and high rate of morbidity and disability is involved. Many methods have been tried including conservative treatment as drugs, electric stimulus, shock wave and electromagnetic field therapy and surgeries as core compression, rotary osteotomy and vascularized bone graft, but neither of them has definitive effect. Recently mesenchymal stem cells (MSCs) and tantalum robust have been widely used in ANFH. They have definite cure effects but advantages and disadvantages should not be neglected. In this paper, we hypothesize that mesenchymal stem cells cultured on tantalum can be used to prevent collapse of the articular surface in patients with ANFH. Unlike current treatment modalities, it would promote the regeneration of femoral head, provide structural support and allow for bony substitution over time.

Effects of Cbfa1 on osteoanagenesis during avascular necrosis of femoral head

We observed the effect of Cbfa1 on bone regeneration and microvessel density (MVD) in the process of avascular necrosis of femoral head (ANFH). Imageology and morphology were taken to verify the success of the ANFH models. Meanwhile, real-time PCR was performed to observe the dynamic expression of Cbfa1. The surface cartilage of the femoral head and the subchondral bone began to degenerate since 4 weeks post-operation; the femoral head cartilage progressively stripped and the subchondral bone necrosis increased with the time; a majority of the femoral head became necrosis, and even collapsed after 8 weeks post-operation. Different from imageology and morphology, the expression of Cbfa1 mRNA was enhanced in the 2nd week post-operation, and was continuously enhanced till the 6th week; then the expression reduced, but was still higher than normal level (P < 0.05). In the process of ANFH, the change of Cbfa1 mRNA expression is earlier than imageology and morphology, and continues to enhance during the process of ANFH, so the signal of bone regeneration starts in the early stage of avascular necrosis of the femoral head. Cbfa1 may be an important cell factor to participate and accommodate the reparation of ANFH. Key words: Core binding factor alpha l, avascular necrosis of femoral head,animal model.

Diagnostic performance of MR imaging in the assessment of subchondral fractures in avascular necrosis of the femoral head

A prospective study was conducted to determine the accuracy of routine magnetic resonance (MR) imaging in correctly identifying subchondral fracture in avascular necrosis of the femoral head without apparent focal collapse on standard radiographs. Spiral computed tomography (CT) with coronal and sagittal reformations and routine MR imaging with spin-echo T1WI and fat-suppressed spin-echo T2WI coronal, axial, and sagittal images were performed in 28 hips of 25 patients (M/F = 20:5; age 16-76 years) suffering from early-stage avascular necrosis of the femoral head on standard radiographs. The MR images were reviewed by a musculoskeletal radiologist and a general radiologist in blinded fashion. Using CT as the standard of reference, the accuracy of MR imaging in diagnosing subchondral fractures in avascular necrosis was evaluated. When the diagnoses of the two readers were compared with each other, only 16 of the 28 diagnoses (57.5%) agreed. Seventeen of the 28 MR imaging readings (60.7%) made by the musculoskeletal radiologist and 15 of the 28 (53.5%) made by the general radiologist agreed with those of the CT standard. False-positive diagnosis (that is, diagnosis of fracture when no fracture could be seen on CT) was more common than false-negative diagnosis. The accuracy of routine MR imaging in the evaluation of subchondral fracture is not satisfactory. False-positive diagnosis is not uncommon. Interpretation of routine MR imaging readout should be guarded.