Efficacy of orthobiologic adjuvants to core decompression for hip preservation in avascular necrosis hip

Abstract

Head preserving modalities in avascular necrosis (AVN) hip are variably effective in early stages, and further options that could prevent head distortion and osteoarthritis are needed. Core decompression (CD) is the most commonly used surgery in the early stages of osteonecrosis with variable rates of success. The present review aimed to determine the effectiveness of bone marrow aspirate concentrate (BMAC), platelet-rich plasma (PRP), bone morphogenetic proteins (BMP) or their combination with CD in early stages of AVN hip, prior to collapse of femoral head. Additionally, any newer unexplored modalities were also searched for and ascertained. PubMed and SCOPUS databases were searched for relevant articles in English language describing CD with aforementioned orthobiologics. We analysed a total of 20 studies published between 2011 and 2020. There were 6 retrospective and 14 prospective studies. PRP showed improved survival and functional outcomes; however, with only three studies, there is inconclusive evidence for its routine utilization. BMAC enhances the efficacy of CD which can further be increased by culture and expansion of cells or combining it with PRP to stimulate growth. In conclusion, CD with BMAC works more efficiently than CD alone prior to collapse of femoral head in AVN. However, PRP needs more evidence for extensive application. Addition of PRP to BMAC or culturing the latter could further enhance the potency of CD + BMAC combination. Very limited data is available for the efficacy of BMP-7 and the role of intraosseous bisphosphonates should be evaluated for a cheaper and potential alternative.

Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis

“…34,35 Its efficacy in pre collapse stages has been proven in literature, however whether or not the indication can be expanded to include the advanced forms of AVN hip, where the subchondral bone and articular cartilage have already collapsed, is a matter of debate. 6 Hernigou et al were the first to evaluate the efficacy of the CD and BMAC in a study that included 32 Steinberg stage 4 AVN hips, out of which 12 cases progressed, requiring THR; the mean Harris Hip Score (HHS) also did not show much improvements (68e74 postoperatively). 30 In the present review the aim was to ascertain the effect of this treatment modality in post collapse stages of AVN hip, by determining the radiographic worsening of stage and need of THR as the primary outcomes.…”

“…12,13 CD alone has been reported to be beneficial in up to 84-95 % in stage 1 and 65% in stage 2 as per Ficat Arlet staging; effects are unpredictable in advanced stages. 6,14,15 Subsequently, BMAC has been used as an adjuvant and reported more beneficial results in early stages of AVN. This prompted the trials of BMAC in the advanced stages with collapsed subchondral bone beyond the crescent stage, to evaluate its feasibility as a hip preserving surgery.…”

Multiple Drilling with Recombinant Human Bone Morphogenetic Protein-2 in Korean Patients with Non-Traumatic Osteonecrosis of the Femoral Head: A Prospective Randomized Pilot Study with a Minimum Two-Year Follow-Up

“…To support the mechanical properties of the sub-chondral surface, vascularized and non-vascularized bone grafts have been implanted in the necrotic lesion along with CD [ 21 ]. In addition, to improve the ability of growth factors to strengthen bone remodeling, various biotechnological adjuvants, such as adjunctive cell therapy, recombinant human bone morphogenetic proteins (rhBMP), and synthetic bone substitutes, have been implemented with CD or MD [ 22 , 23 , 24 ]. However, to our knowledge, there is a lack of evidence regarding the clinical efficacy of MD combined with rhBMP-2 and beta-tricalcium phosphate (β-TCP) for non-traumatic ONFH.…”

Efficacy of tantalum rod insertion for preventing femoral head collapse in osteonecrosis in a paediatric population: a pilot study

“…Surgical joint preserving techniques that have been described are decompression, decompression and non-vascularized or vascularized bone grafting, trapdoor grafting, rotational osteotomies, tantalum rod insertion and various arthroscopic techniques [ 14 , 15 ]. More recently this has involved the use of growth factors, stem cells, bone marrow aspirate concentrate and platelet-rich plasma as adjuncts to surgical techniques [ 16 , 17 ].…”