ObjectiveTo explore the clinical efficacy and safety of ultrasound-guided intra-articular injection of platelet-rich plasma (PRP) in the treatment of avascular necrosis of the femoral head.MethodsWe retrospectively collected and analyzed the clinical characteristics, imaging data, and clinical outcomes of patients with femoral head necrosis who received ultrasound-guided intra-articular PRP injection in the Department of Rehabilitation Medicine of Sun Yat-sen Memorial Hospital, Sun Yat-sen University between June 2019 and June 2020. All the patients received 4 injections at one-week intervals. The Visual Analogue Scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Harris Hip Joint Function Scale (HHS) were evaluated before treatment and 1 month, 3 months, and 6 months after the first injections. Adverse events were recorded. The normally distributed data were presented as mean±standard deviation, and analyzed by one-way repeated measures analysis of variance; the non-normally distributed data were presented as median (lower quartile, upper quartile), and analyzed by Friedman test.ResultsA total of 29 patients were included. According to the Association Research Circulation Osseous classification standard, 2 patients were classified as stageⅠ, 11 as stageⅡ, 11 as stage Ⅲ, and 5 as stage Ⅳ. Before treatment and 1 month, 3 months, and 6 months after treatment, the VAS scores were 7.0 (5.5, 8.0), 4.0 (3.0, 5.0), 3.0 (2.0, 3.0), and 3.0 (2.0, 5.0), respectively, the WOMAC scores were 39.27±11.70, 28.34±8.08, 22.82±6.09, and 24.13±7.55, respectively, and the HHS were 46.0 (40.0, 64.0), 71.0 (57.5, 75.0), 78.0 (68.0, 80.5), and 78.0 (64.0, 80.0), respectively. The time effects in VAS (χ2=65.423, P<0.001), WOMAC (F=46.710, P<0.001), and HHS (χ2=66.347, P<0.001) were all statistically significant. There were significant differences in each index between the values 1 month, 3 months, and 6 months after treatment and those before treatment respectively, and there was also a significant difference in each index between the value 1 month after treatment and that 3 months after treatment (P<0.05). There was no significant difference in any indicator between the value 6 months after treatment and that 3 months after treatment (P>0.05). Significant difference was shown between the value 6 months after treatment and that 1 month after treatment in WOMAC (P=0.016), but not in VAS or HHS (P>0.05). No obvious adverse event was reported during the follow-up period.ConclusionsUltrasound-guided intra-articular PRP injection can effectively alleviate the pain and improve the hip joint function of patients with femoral head necrosis for at least 6 months. However, randomized controlled studies with a larger sample size and longer-term follow-up are needed in the future to confirm the efficacy and safety of PRP injection in femoral head necrosis.
Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in the clinic. Although the exact pathophysiological mechanism is not fully understood, it is believed to be closely related to the interruption of intra-bone circulation and eventual bone tissue death. The prevention and treatment of ONFH is always a great challenge for orthopedists. The diagnostic level of ONFH has been continuously improved with the development of imaging techniques such as MRI and the in-depth understanding of the disease in recent years.There are many treatment methods for ONFH, which are generally considered individually and comprehensively according to factors such as the patient’s age, osteonecrosis stage, classification, and compliance with joint-sparing treatment. There is currently no unified standard. ONFH staging and classification play an important reference value for doctors to choose treatment options. In recent years, based on the characteristics of ONFH in Chinese people, the academic community has proposed Chinese staging and China-Japan Friendship Hospital (CJFH) classification. The consensus also introduces them together with the international Association Research Circulation Osseous (ARCO) staging to provide guidance for individualized treatment of ONFH. In order to further standardize the diagnosis of ONFH and expand the treatment of ONFH, the Association Related to Circulation Osseous, Chinese Microcirculation Society (CSM-ARCO) organized domestic experts in the field of ONFH to jointly formulate the expert consensus, in order to provide reference for the standardized diagnosis of ONFH and the selection of individualized diagnosis and treatment techniques.
Objective To summarize the research progress on the role of macrophage-mediated osteoimmune in osteonecrosis of the femoral head (ONFH) and its mechanisms. Methods Recent studies on the role and mechanism of macrophage-mediated osteoimmune in ONFH at home and abroad were extensively reviewed. The classification and function of macrophages were summarized, the osteoimmune regulation of macrophages on chronic inflammation in ONFH was summarized, and the pathophysiological mechanism of osteonecrosis was expounded from the perspective of osteoimmune, which provided new ideas for the treatment of ONFH. Results Macrophages are important immune cells involved in inflammatory response, which can differentiate into classically activated type (M1) and alternatively activated type (M2), and play specific functions to participate in and regulate the physiological and pathological processes of the body. Studies have shown that bone immune imbalance mediated by macrophages can cause local chronic inflammation and lead to the occurrence and development of ONFH. Therefore, regulating macrophage polarization is a potential ONFH treatment strategy. In chronic inflammatory microenvironment, inhibiting macrophage polarization to M1 can promote local inflammatory dissipation and effectively delay the progression of ONFH; regulating macrophage polarization to M2 can build a local osteoimmune microenvironment conducive to bone repair, which is helpful to necrotic tissue regeneration and repair to a certain extent. Conclusion At present, it has been confirmed that macrophage-mediated chronic inflammatory immune microenvironment is an important mechanism for the occurrence and development of ONFH. It is necessary to study the subtypes of immune cells in ONFH, the interaction between immune cells and macrophages, and the interaction between various immune cells and macrophages, which is beneficial to the development of potential therapeutic methods for ONFH.
Objective To investigate the safety and efficacy of a new biodegradable magnesium internal fixation screw for vascularized iliac bone flap grafting in treatment of osteonecrosis of the femoral head (ONFH). Methods Patients with ONFH admitted between July 2020 and February 2021 were selected as the research objects, and 20 patients (20 hips) met the selection criteria and were included in the study. The patients were divided into two groups (n=10) by central random method. The iliac bone flap was fixed with a new biodegradable magnesium internal fixation screw in the trial group, and the iliac bone flap was wedged directly in the control group. There was no significant difference (P>0.05) in gender, age, and side, type, Association Research Circulation Osseous (ARCO) stage, and disease duration of ONFH between the two groups. The operation time and intraoperative blood loss of the two groups were recorded. Laboratory tests were performed at each time point before and after operation, including white blood cell (WBC), electrolytes (K, Ca, P, Mg), blood urea nitrogen (BUN), serum creatinine (Scr), glomerular filtration rate (eGFR), lymphocyte ratio (CD4/CD8), immunoglobulin G (IgG), IgM, alanine transaminase (ALT), aspartate aminotransferase (AST). After operation, Harris score was used to evaluate the hip joint function. CT of the hip joint and X-ray films in anteroposterior and frog positions of the pelvis were used to review the iliac bone flap position, fusion, and screw biodegradation in the trial group. Results The vital signs of the two groups were stable, the incisions healed by first intention, and no adverse events occurred after operation. One patient in the control group refused to return to the hospital for follow-up at 3 months after operation, and 1 patient in the trial group refused to return to the hospital for follow-up at 1 year after operation. The rest of the patients completed the follow-up at 2 weeks, 3 months, 6 months, and 1 year after operation. Laboratory tests showed that there was no significant difference in WBC, electrolytes (K, Ca, P, Mg), BUN, Scr, eGFR, CD4/CD8, IgG, IgM, ALT, and AST between the two groups at each time point before and after operation (P>0.05). The operation time and intraoperative blood loss of the trial group were significantly less than those of the control group (P<0.05). The Harris scores of the two groups at 1 year significantly increased when compared with the values before operation and at 6 months after operation (P<0.05). There was no significant difference in Harris score between the two groups at each time point (P>0.05). Postoperative CT of hip joint and X-ray films of pelvis showed that the iliac bone flap reached osseous fusion with the fenestration of the head and neck junction of femoral head in the two groups at 1 year after operation, and no loosening or shedding of iliac bone flap was observed during follow-up. In the trial group, there were signs of dissolution and absorption of the new biodegradable magnesium internal fixation screws after operation, and the diameter of the screws gradually decreased (P<0.05); no screw breakage or detachment occurred during follow-up. Conclusion In the treatment of ONFH with vascularized iliac bone flap grafting, the new biodegradable magnesium internal fixation screws can fix the iliac bone flap firmly. Compared with the traditional iliac bone flap wedging directly, it has a shorter operation time, less intraoperative blood loss, and can obtain similar joint function.
Objective To evaluate the effectiveness of multiple small-diameter drilling decompression combined with hip arthroscopy for early oeteonecrosis of the femoral head (ONFH). Methods Between March 2010 and December 2013, 91 patients with early ONFH were treated with the operation of multiple small-diameter drilling decompression combined with hip arthroscopy in 39 cases (53 hips, group A) or with drilling decompression alone in 52 cases (74 hips, group B). The patients in 2 groups had obvious hip pain and limited motion before operation. There was no significant difference in gender, age, etiology, effected side, stage of osteonecrosis, and preoperative Harris score between 2 groups (P>0.05). Results All operations succeeded and all incisions healed by first intention. The operation time was significantly longer in group A [(73.3±10.6) minutes] than in group B [(41.5±7.2) minutes] (t=8.726, P=0.000). Temporary of sciatic nerve apraxia after operation occurred in 2 patients of group A, and no complication occurred in other patients. Patients were followed up 24-52 months (mean, 39.3 months) in group A and 24-48 months (mean, 34.6 months) in group B. At last follow-up, the Harris scores were 83.34±8.76 in group A and 76.61±9.22 in group B, showing significant differences when compared between 2 groups (t=–4.247, P=0.029) and when compared with preoperative values in 2 groups (t=–10.327, P=0.001; t=–8.216, P=0.008). X-ray films showed that the collapse of the femoral head was observed in 6 hips (1 hip at stage Ⅰand 5 hips at stage Ⅱ) in group A, and in 16 hips (4 hips at stageⅠand 12 hips at stage Ⅱ) in group B; and hip arthroplasty was performed. The total effective rates were 88.68% (47/53) in group A and 78.38% (58/74) in group B, respectively; showing significant difference between 2 groups (χ2=5.241, P=0.041). Conclusion Multiple small-diameter drilling decompression combined with hip arthroscopy is effective in pain relief, improvement of hip function, slowing-down the process of femoral head necrosis, delaying the need for total hip arthroplasty in patients with early ONFH.
Objective To compare the short-term effectiveness between primary cemented and uncemented total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH) after renal transplantation. Methods The clinical data were retrospectively analyzed from 18 patients (21 hips) with ONFH after renal transplantation undergoing cemented THA in 11 cases (13 hips) (cemented group) and uncemented THA in 7 cases (8 hips) (uncemented group) between February 2005 and February 2012. There was no significant difference in gender, age, disease duration, ONFH stage, preoperative Harris score, and bone density between 2 groups (P gt; 0.05). Postoperative complications were observed in 2 groups; the hip function was assessed based on Harris scores; X-ray film was used to observe the prosthetic situation. Results All the wounds healed by first intention. The patients were followed up 6-77 months (mean, 46 months) in the cemented group, and 4-71 months (mean, 42 months) in the uncemented group. Femoral prosthesis infection occurred in 1 case (1 hip) respectively in each group; hip dislocation, femoral prosthesis loosening, and acetabular prosthesis loosening occurred in 1 case (1 hip) of the cemented group, respectively. At last follow-up, the incidences of postoperative complications and revision rate of the cemented group were 30.7% (4/13) and 23.1% (3/13) respectively, which were significantly higher than those of the uncemented group [12.5% (1/8) and 0 (0/8)] (P=0.047, P=0.040). Harris score was significantly increased to 94.1 ± 3.7 in the uncemented group and 90.0 ± 4.2 in the cemented group, showing significant differences compared with the preoperative scores in 2 groups (P lt; 0.05), but there was no significant difference between 2 groups (t=1.815, P=0.062). Postoperative X-ray films showed that the initial position of the prosthesis was satisfactory. At last follow-up, the bone fixation, fibrous stability, and loosening of the femoral prosthesis and loosening of acetabular prosthesis occurred in 9 hips, 3 hips, 1 hip, and 1 hip of the cemented group, respectively; bone fixation of the femoral prosthesis and stability of acetabular prosthesis were observed in all hips of the uncemented group. There was no heterotopic ossification in 2 groups. Conclusion Uncemented THA after renal transplantation can obtain satisfactory short-term effectiveness, and uncemented THA is better than the cemented THA; however, the middle- and long-term effectivenesses need further observation．
ObjectiveTo explore the predictive effect of the femoral neck strength composite indexes on femoral head collapse in non-traumatic osteonecrosis of the femoral head (ONFH) compared with bone turnover marker.MethodsThe non-traumatic ONFH patients who were admitted and received non-surgical treatment between January 2010 and December 2016 as the research object. And 96 cases (139 hips) met the selection criteria and were included in the study. There were 54 males (79 hips) and 42 females (60 hips), with an average age of 40.2 years (range, 22-60 years). According to whether the femoral head collapsed during follow-up, the patients were divided into collapsed group and non-collapsed group. The femoral neck width, hip axis length, height, body weight, and bone mineral density of femoral neck were measured. The femoral neck strength composite indexes, including the compressive strength index (CSI), bending strength index (BSI), and impact strength index (ISI), were calculated. The bone turnover marker, including the total typeⅠcollagen amino terminal elongation peptide (t-P1NP), β-crosslaps (β-CTx), alkaline phosphatase (ALP), 25 hydroxyvitamin D [25(OH)D], and N-terminal osteocalcin (N-MID), were measured. The age, gender, height, body weight, body mass index (BMI), bone mineral density of femoral neck, etiology, Japanese Osteonecrosis Investigation Committee (JIC) classification, femoral neck strength composite indexes, and bone turnover marker were compared between the two groups, and the influencing factors of the occurrence of femoral head collapse were initially screened. Then the significant variables in the femoral neck strength composite indexes and bone turnover marker were used for logistic regression analysis to screen risk factors; and the receiver operating characteristic (ROC) curve was used to determine the significant variables’ impact on non-traumatic ONFH. ResultsAll patients were followed up 3.2 years on average (range, 2-4 years). During follow-up, 46 cases (64 hips) had femoral head collapse (collapsed group), and the remaining 50 cases (75 hips) did not experience femoral head collapse (non-collapsed group). Univariate analysis showed that the difference in JIC classification between the two groups was significant (Z=–7.090, P=0.000); however, the differences in age, gender, height, body weight, BMI, bone mineral density of femoral neck, and etiology were not significant (P>0.05). In the femoral neck strength composite indexes, the CSI, BSI, and ISI of the collapsed group were significantly lower than those of the non-collapsed group (P<0.05); in the bone turnover marker, the t-P1NP and β-CTx of the collapsed group were significantly lower than those of the non-collapsed group (P<0.05); there was no significant difference in N-MID, 25(OH)D or ALP between groups (P>0.05). Multivariate analysis showed that the CSI, ISI, and t-P1NP were risk factors for femoral collapse in patients with non-traumatic ONFH (P<0.05). ROC curve analysis showed that the cut-off points of CSI, BSI, ISI, t-P1NP, and β-CTx were 6.172, 2.435, 0.465, 57.193, and 0.503, respectively, and the area under the ROC curve (AUC) were 0.753, 0.642, 0.903, 0.626, and 0.599, respectively. ConclusionThe femoral neck strength composite indexes can predict the femoral head collapse in non-traumatic ONFH better than the bone turnover marker. ISI of 0.465 is a potential cut-off point below which future collapse of early non-traumatic ONFH can be predicted.
Objective To explore the differences between transient osteoporosis of the hi p (TOH) and bone marrow edema (BME) associated with osteonecrosis of the femoral head (ONFH) in terms of cl inical practice and imaging. Methods From January 2006 to February 2008, 5 hips of TOH in 5 cases (1 male and 4 females, aged 29-42 years) and 67 hips of BME associated with ONFH in 63 cases (53 males and 10 females, aged 18-70 years) were analyzed. According to ARCO classification, there were 23 hi ps of stage II, 43 hi ps of stage III, and 1 hi p of stage IV. The induced factors, the degree of pain, the duration of pain and commemorative symptoms were compared. The X-ray, MRI and ECT were also compared. Results There were no differences in induced factors, the degree of pain, joint effusion and ECT between TOH and BME associated with ONFH. TOH had no risk factors, antecedent symptoms and commemorative pain. There were 2 hips with TOH which showed osteopenia on X-ray films. The location of edema was in the superior part or the whole femoral head.A total of 65 hips with BME associated with ONFH had related causes of disease, 10 had antecedent pain and 59 had change of hardening on X-ray films. The X-ray films showed sclerotic area and the edema changes on MRI surrounded the necrotic lesion. The pain just amel iorated when BME disappeared. Conclusion There are differences between TOH and BME associated with ONFH on symptoms, X-ray films and MRI.
Objective To perfect the theory system of minimally invasive treatment for osteonecrosis of the femoral head (ONFH) with β tricalcium phosphate (β-TCP) bioceramic system and evaluate the effectiveness. Methods Eighteen New Zealand white rabbits aged 7-8 months were used to establish an animal model to verify the vascularization of porous β-TCP bioceramic rods. Micro-CT based three-dimensional reconstruction and fluorescence imaging were used to display the new blood vessels at 4, 8, and 12 weeks after operation. The inserting depth, number and diameter of vessels in the encapsulated area were analyzed. Nine pig femoral specimens were randomly divided into 3 groups (n=3): group A was normal femur; group B had cavity (core decompression channel+spherical bone defect in femoral head); in group C, mixed bioceramic granules were implanted to fill the defect in femoral head, and porous β-TCP bioceramic rod was implanted into decompression channel. The stiffness and yield load of specimens were analyzed by biomechanical test. A multicenter retrospective study was conducted to analyze 200 patients (232 hips) with femoral head necrosis treated with bioceramic system in 7 hospitals in China between January 2012 and July 2018. There were 145 males and 55 females, with an average age of 42 years (range, 17-76 years). According to the Association Research Circulation Osseous (ARCO) stage, 150 hips were in stage Ⅱ and 82 hips in stage Ⅲ. Postoperative imaging assessment was carried out regularly, and hip function was evaluated by Harris score. The effectiveness of ARCO stage Ⅱ and Ⅲ was also compared. Results Animal experiments showed that blood vessels could grow into the encapsulated area and penetrate it at 12 weeks. The inserting depth, number and diameter of blood vessels in the encapsulated area gradually increased, and there was significant difference between different time points (P<0.05). Biomechanical tests showed that the stiffness and yield load of specimens in groups B and C were significantly lower than those in group A, while the yield load in group B were significantly lower than that in group C (P<0.05). The stiffness in group C was restored to 41.52%±3.96% in group A, and the yield load was restored to 46.14%±7.85%. Clinical study showed that 200 patients were followed up 6-73 months, with an average of 22.7 months. At last follow-up, 12 patients (16 hips) underwent total hip arthroplasty, and the hip survival rate was 93.10%. According to the imaging evaluation, 184 hips (79.31%) were stable and 48 (20.69%) were worse. Harris score (79.3±17.3) was significantly higher than that before operation (57.3±12.0) (t=18.600, P=0.000). The excellent rate of hip function was 64.22% (149/232). The survival rate of hip joint, imaging score and Harris score of patients in ARCO stage Ⅱ were better than those in ARCO stage Ⅲ (P<0.05). Conclusion β-TCP bioceramic system can guide the abundant blood supply of greater trochanter and femoral neck to the femoral head to promote repair; it can partly restore the mechanical properties of the femoral head and neck in the early stage, providing a new minimally invasive hip-preserving method for patients with ONFH, especially for those in early stage.
ObjectiveTo evaluate the clinical and radiographic outcomes of hip resurfacing arthroplasty (HRA) for treating osteonecrosis of the femoral head (ONFH) in young and middle-aged patients. MethodsBetween January 2008 and April 2009, 34 patients with ONFH underwent HRA. There were 19 males and 15 females with an average age of 54 years (range, 33-59 years). Of 34 cases, 16 left hips and 18 right hips were involved, including 9 cases of alcoholinduced ONFH, 8 cases of steroid-induced ONFH, 7 cases of traumatic ONFH, and 10 cases of unexplained ONFH. According to modified Ficat classification system, 26 hips were rated as stage III, and 8 hips as stage IV. The Harris hip score (HHS) and modified University of California, Los Angeles (UCLA) activity score were used to evaluate the clinical results. Migration of prosthesis was assessed on the anteroposterior radiographs. The abduction angle was measured on the acetabular side. On the femoral side, varus-valgus shift was determined by measurement of stem-shaft angle. The axial collapse of femoral component was assessed with the component-lateral cortex ratio. ResultsHealing of incision by first intention was achieved in all patients without complications of infection and thrombosis of deep vein of lower extremities. Thirty-two patients were followed up 78 months on average (range, 70-84 months). No implant loosening, infection, femoral neck fracture, dislocation, and inflammatory pseudotumor were observed. At last follow-up, the HHS score was significantly increased to 95.22±1.47 from preoperative 50.10±2.27 (t=1.510, P=0.008). Modified UCLA activity score was significantly increased to 7.70±1.13 from preoperative 3.90±0.90 (t=0.830, P=0.003). The abduction angle, stemshaft angle, and compotent-lateral cortex ratio showed no significant difference between at 3 days after operation and last follow-up (P>0.05). ConclusionIf the indication of operation is mastered strictly, HRA may be effective in treatment for ONFH at Ficat stage III or IV in young and middle-aged patients.