Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials

Abstract

Background Various Joint-preserving therapy (JPT) methods have been performed and tried in recent decades, but their results and efficacy were inconsistent and controversial. The purpose of this study is to evaluate its effectiveness and whether there are statistical differences in treatment between different interventions based on published RCT studies. Methods Following the PRISMA-NMA checklist, Medline, EMBASE, Web of Science, and Cochrane Library databases were searched and collected related RCT studies. The sources were searched from inception up to October 30, 2020. The primary outcomes including the rate of radiographic progression and conversion to THA and the secondary outcome -Harris Hip Scores (HHS) were extracted and compared in a Network meta-analysis. Results Seventeen RCT studies involving 784 patients (918 hips) with seven interventions including CD (core decompression), CD + BG (bone graft), CD + TI (tantalum rod implantation), CD + CT (Cell therapy), CD + BG + CT, VBG (vascularized bone graft), and nonsurgical or conservative treatment for ONFH were evaluated. In the radiographic progression results, CD + CT showed a relatively better result than CD, CD + BG and non-surgical treatment, the surface under the cumulative ranking curve (SUCRA) plot displayed that CD + CT (96.4%) was the best, followed by CD (64.1%).In conversion to THA results, there were no significant differences between the JPT methods and non-surgical treatment. In HHS, there was also no significant difference, other than CD + BG showed a statistical difference than non-surgical treatment only in terms of Cis, but the SUCRA was highest in non-surgical treatment (80.5%) followed by CD + CT (72.8%). Conclusions This Net-work meta-analysis demonstrated that there was no statistical difference in the outcome of radiographic progression and conversion to THA, also in HHS, other than CD + CT showed a relatively superior result in radiographic progression than nonsurgical treatment, namely, it’s maybe an effective method for delaying disease progression or reducing disease development based on current evidence.

Application of protective weight-bearing in osteonecrosis of the femoral head: A systematic review and meta-analysis of randomized controlled trials and observational studies

“…In a previous meta-analysis, Mont defined an HHS > 80 as clinical success and reported a higher clinical success rate in the surgical hip preservation group (64%) than in the nonsurgical treatment group (23%) ( 15 ). However, in a recent network meta-analysis, the HHS of the hip preservation surgery group was not significantly higher than that of the nonsurgical treatment group ( 17 ). Neumayr et al ( 24 ) used the modified HHS score and found that improvements in the scores did not significantly differ between the two groups.…”

“…Core decompression (CD) is the most common surgery for the treatment of ONFH prior to collapse, and the THA rate at 26 months after surgery is approximately 38% ( 35 – 37 ). Previous studies have shown that the THA rates do not significantly differ between nonsurgical and CD treatments ( 17 ). This finding was also observed in this study, and the THA rate with protective weight-bearing was approximately 40%.…”

“…In previous studies, researchers reported the general futility of conservative treatment in delaying progression to THA ( 14 ) and indicated that protective weight-bearing can only alleviate symptoms, such as pain ( 13 , 15 , 16 ). In several recent studies, researchers have shown that the clinical efficacy of conservative treatment is not inferior to that of hip preservation surgery ( 17 – 19 ). Protective weight-bearing is the most straightforward method used to relieve stress on the femoral head, and it is readily accepted by doctors and patients and recommended in many guidelines ( 13 , 20 , 21 ).…”

Implantation of core tract autologous bone into decompressed lesion in the core decompression for osteonecrosis of the femoral head

“…Till date, however, no statistically signi cant differences in the radiological progression of necrosis and the rate of conversion to arthroplasty, as well as PROM between surgical procedures regarding CD, have been reported 12,13,17,19,21,22 . Only cell therapy combined with CD has shown relatively superior outcomes regarding the radiological progression of ON 11,12,23−27 .…”

“…Several attempts have been made to improve the clinical outcomes by combining various procedures, such as vascularized or non-vascularized bone grafts, tantalum rods, and cell therapy with conventional CD [8][9][10] . In several randomized controlled trials (RCT) and meta-analyses, CD combined with cell therapy showed superior clinical outcomes in patients with early ONFH without head collapse [11][12][13] . Notably, the results of these procedures are still inconsistent among studies, and the evidence is too weak to build a general consensus for a treatment algorithm 14 .…”