OBJECTIVE: At present, the core decompression (CD) has become the main surgical procedure for the treatment of osteonecrosis of the femoral head (ONFH); however, the CD surgery requires high operator experience and repeated fluoroscopy increases the radiation damage to patients, and medical staff. This article compares the clinical efficacy of robot-assisted and freehand CD for ONFH by meta-analysis.
METHODS: Computer searches of PubMed, Web of Science, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, China Science and Technology Journal Database, WanFang, and Chinese BioMedical Literature Database were conducted from the time of database inception to November 15, 2023. The literature on the clinical efficacy of robot-assisted and freehand CD in the treatment of ONFH was collected. Two researchers independently screened the literature according to the inclusion and exclusion criteria, extracted data, and strictly evaluated the quality of the included literature. Outcome measures encompassed operative duration, intraoperative blood loss volume, frequency of intraoperative fluoroscopies, visual analog scale (VAS) score, Harris hip score (HHS), complications, and radiographic progression. Data synthesis was carried out using Review Manager 5.4.1 software. The quality of evidence was evaluated according to Grades of Recommendation Assessment Development and Evaluation (GRADE) standards.
RESULTS: Seven retrospective cohort studies involving 355 patients were included in the study. The results of meta-analysis showed that in the robot-assisted group, the operative duration (MD = -17.60, 95% CI: -23.41 to -11.78, P < 0.001), intraoperative blood loss volume (MD = -19.98, 95% CI: -28.84 to -11.11, P < 0.001), frequency of intraoperative fluoroscopies (MD = -6.60, 95% CI: -9.01 to -4.20, P < 0.001), and ΔVAS score (MD = -0.45, 95% CI: -0.67 to -0.22, P < 0.001) were significantly better than those in the freehand group. The GRADE evidence evaluation showed ΔVAS score as low quality and other indicators as very low quality. There was no significant difference in the terms of ΔHHS (MD = 0.51, 95% CI: -1.34 to 2.35, P = 0.59), complications (RR = 0.30, 95% CI: 0.03 to 2.74, P = 0.29), and radiographic progression (RR = 0.50, 95% CI: 0.25 to 1.02, P = 0.06) between the two groups.
CONCLUSIONS: There is limited evidence showing the benefit of robot-assisted therapy for treatment of ONFH patients, and much of it is of low quality. Therefore, caution should be exercised in interpreting these results. It is recommended that more high-quality studies be conducted to validate these findings in future studies.
BACKGROUND: https://www.crd.york.ac.uk/prospero/ #recordDetails, CRD42023420593.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a common clinical disease. Improper treatment can lead to femoral head collapse and hip joint dysfunction. Core decompression is particularly important for early ONFH. However, subtrochanteric fractures after core decompression cause some clinical problems.
METHODS: This article describes a 34-year-old male patient with early ONFH. After core decompression, he suffered a subtrochanteric fracture of the femur while bearing weight on the affected limb when going up stairs. He was subsequently treated with open reduction and intramedullary nail fixation.
CONCLUSIONS: When core decompression is used to treat ONFH, the location or size of the drill hole, whether a tantalum rod or bone is inserted, and partial weight-bearing of the affected limb may directly affect whether a fracture occurs after surgery. It is hoped that this case report can provide a reference for clinical orthopedic surgeons in the treatment of early ONFH.

BACKGROUND: Accumulated clinical trials had been focused on stem cell therapy in combination of core decompression (CD) in the treatment of avascular necrosis of the femoral head (ANFH). Nonetheless, the results were inconclusive. Here, we performed a systematic review and meta-analysis of previous randomized controlled trials (RCTs) and retrospective studies to assess whether combined stem cell augmentation with CD improved the outcomes of ANFH compared with CD alone.
METHODS: The current study included 11 RCTs and 7 retrospective studies reporting the clinical outcomes of a total of 916 patients and 1257 hips. 557 and 700 hips received CD and CD plus stem cell therapy, respectively. To compare CD with CD plus stem cell therapy, we examined the clinical evaluating scores, the occurrence of the femoral head, radiologic progression and conversion to total hip arthroplasty (THA).
RESULTS: Only 10 studies reported significantly greater improvement in hip functions while combining stem cell procedure with CD. The pooled results in subgroup analysis indicated that stem cell group had a lower collapse rate on a mid-term basis (P = 0.001), when combined with mechanical support (P < 0.00001), and with extracted stem cells (P = 0.0002). Likewise, stem cell group had a lower radiographic progression rate at 2- to 5-year follow-up [P = 0.003], when combined with structural grafting (P < 0.00001), and with extracted stem cells (P = 0.004). Stem cell therapy resulted in an overall lower THA conversion rate (P < 0.0001) except that at a follow-up longer than 5 years.
CONCLUSIONS: Stem cell therapy combined with core decompression was more effective in preventing collapse, radiographic progression and conversion to THA. Trial Registration The current protocol has been registered in PROSPERO with the registration number: CRD42023417248.

Bone marrow edema (BME) of the hip is a radiological-clinical condition with symptoms ranging from asymptomatic to severe, and it is characterized by increased interstitial fluid within the bone marrow, usually at the femur. Depending on the etiology it can be classified as primary or secondary. The primary cause of BME is unknown, while the secondary forms include traumatic, degenerative, inflammatory, vascular, infectious, metabolic, iatrogenic, and neoplastic etiologies. BME could be classified as reversible or progressive. Reversible forms include transient BME syndrome and regional migratory BME syndrome. Progressive forms include avascular necrosis of the femoral head (AVNH), subchondral insufficiency fracture, and hip degenerative arthritis. The diagnosis can be difficult, because at the beginning, the outbreak of hip pain, typically acute and disabling without any prior trauma or exceptional physical activity, is poorly supported by radiographic findings. MRI is the gold standard, and it shows an area of intermediate signal on T1-weighted MRI scans and a high signal on T2-weighted scans, usually lacking sharps margins. In the reversible form, BME is typically self-limiting, and it can be managed conservatively by means of pharmacological and physical therapy. Surgery is generally required for progressive forms in patients who failed non-operative treatment, and it ranges from femoral head and neck core decompression to total hip arthroplasty.

BACKGROUND: Much of the literature on osteonecrosis has traditionally focused on the hip, which remains the most common site for this disease. The shoulder and the knee are the second most frequently affected sites (both approximately 10% of the incidence). There are a variety of techniques for managing this disease, and it is important to optimize this for our patients. This review aimed to compare the results of core decompression (CD) vs. nonoperative modalities for the treatment of osteonecrosis of the humeral head, including (1) success rate defined as lack of progression to further procedures (shoulder arthroplasty) and no need for further intervention; (2) clinical results (patient-reported pain and functional scores); and (3) radiological outcomes.
METHODS: We queried PubMed and found 15 reports that fit the inclusion criteria for studies concerning the use of CD as well as studies discussing nonoperative treatment for stage I-III osteonecrotic lesions of the shoulder. A total of 9 studies encompassed 291 shoulders that underwent CD analyzed at a mean follow-up of 8.1 years (range, 67 months-12 years), and 6 studies examined 359 shoulders that underwent nonoperative management at a mean follow-up of 8.1 years (range, 35 months-10 years). Outcomes of CD and nonoperative management included success rate, number of shoulders requiring shoulder arthroplasty, and evaluation of several normalized patient-reported outcomes. We also assessed radiographic progression (pre- to postcollapse or further collapse progression).
RESULTS: The mean success rate of CD for avoiding further procedures was 76.6% (226 of 291 shoulders) in stage I through stage III. Stage III shoulders avoided shoulder arthroplasty in 63% (27 of 43 shoulders). Nonoperative management resulted in a success rate of 13%, P < .001. In the CD studies, 7 of 9 showed improvements in clinical outcome measurements compared with 1 of 6 of the nonoperative studies. Radiographically, there was less progression in the CD group (39 of 191 shoulders [24.2%]) vs. the nonoperative group (39 of 74 shoulders [52.3%]) (P < .001).
CONCLUSIONS: Given the high success rate and positive clinical outcomes reported, CD is an effective method for management, especially when compared with nonoperative treatment methods for stage I-III osteonecrosis of the humeral head. The authors believe that it should be used as treatment to avoid arthroplasty in patients who have osteonecrosis of the humeral head.

UNASSIGNED: Various joint preserving treatments are available for use in Avascular Necrosis of the femoral head. Most of these are effective in the pre-collapse stage of the disease. This review aimed to evaluate the effectiveness of core decompression and Bone Marrow Aspirate Concentrate in various stages of AVN, in modifying the progression of the disease and the need for hip replacement.
UNASSIGNED: The Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews reporting guidelines were followed. The literature search was conducted from inception till 2nd May 2021, on the PUBMED, SCOPUS, and Google Scholar search engines, using \"bone marrow aspirate concentrate osteonecrosis femur\" and \"bmac osteonecrosis femur\" as the keywords. In all these studies, Core Decompression with Bone marrow Aspirate concentrate was performed. The evaluation was done based on the progression of osteonecrosis, improvement in functional outcomes and the conversion to total hip arthroplasty.
UNASSIGNED: We have analyzed 612 hips from11 studies, based on our inclusion and exclusion criteria. The mean age of the patients was 38.27 years. There was a predominance of males. The grade of AVN ranged from grade 1 to 4. The average follow-up period of the cases ranged from 2 to 12 years (average: 4.38 years). The functional scores were improved in the majority of cases. Radiographic progression occurred in 23.5% of hips, and the Total Hip Arthroplasty was performed in 14.9% of hips.
UNASSIGNED: Core decompression with Bone Marrow Aspirate Concentrate in pre-collapse stages of the disease is beneficial in improving the functions scores and for reducing the radiological progression of the disease and need for total hip arthroplasty, in the majority of cases.

OBJECTIVE: The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone.
METHODS: We searched the PubMed, Embase, Web of Science, and Cochrane Library databases until June 2020. All randomized controlled trials (RCTs) and clinical controlled trials (CCTs) comparing CD alone and CD combined with other measures (CD + cell therapy, CD + bone grafting, CD + porous tantalum rod, etc.) for the treatment of ONFH were considered eligible for inclusion. The primary outcomes of interest were Harris Hip Score (HHS), ONFH stage progression, structural failure (collapse) of the femoral head, and conversion to total hip arthroplasty (THA). The pooled data were analyzed using Review Manager 5.3 software.
RESULTS: A total of 20 studies with 2,123 hips were included (CD alone = 768, CD combined with other treatments = 1,355). The combination of CD with other therapeutic interventions resulted in a higher HHS (mean difference (MD) = 6.46, 95% confidence interval (CI) = 2.10 to 10.83, p = 0.004) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (MD = -10.92, 95% CI = -21.41 to -4.03, p = 0.040) and a lower visual analogue scale (VAS) score (MD = -0.99, 95% CI = -1.56 to -0.42, p < 0.001) than CD alone. For the rates of disease stage progression, 91 (20%) progressed in the intervention group compared to 146 (36%) in the control group (odds ratio (OR) = 0.32, 95% CI = 0.16 to 0.64, p = 0.001). In addition, the intervention group had a more significant advantage in delaying femoral head progression to the collapsed stage (OR = 0.32, 95% CI = 0.17 to 0.61, p < 0.001) and reducing the odds of conversion to THA (OR = 0.35, 95% CI = 0.23 to 0.55, p < 0.001) compared to the control group. There were no serious adverse events in either group. Subgroup analysis showed that the addition of cell therapy significantly improved clinical and radiological outcomes compared to CD alone, and this approach appeared to be more effective than other therapies, particularly in precollapse (stage I to II) ONFH patients.
CONCLUSIONS: There was marked heterogeneity in the studies. There is a trend towards improved clinical outcomes with the addition of stem cell therapy to CD. Cite this article: Bone Joint Res 2021;10(7):445-458.

BACKGROUND: Avascular necrosis (AVN) of femoral head is commonly seen in middle age groups and in its advanced stages, it is a common indication for total hip replacements (THRs). These patients invariably require revision surgeries in their lifetime and modalities to delay the first arthroplasty are necessary. Core decompression (CD) with bone marrow aspirate concentrate (BMAC) have proved successful in early stages of AVN, but their role in advanced stages remains unclear. The present review was done to assess the same.
OBJECTIVE: Is CD and BMAC combination effective in delaying radiographic progression and THRs in post collapse stages of AVN hip?
METHODS: A systematic review and meta-analysis was conducted to determine the overall efficacy of CD and BMAC in post collapse stages of AVN hip and to specifically compare primary outcomes like radiographic progression along with need of THR, with CD alone.Three data bases (PubMed, EMBASE and SCOPUS) were searched to identify relevant articles.
RESULTS: The present review included 12 studies with 3 studies included in the meta-analysis. There were 270 hips across the 12 studies out of which 196 hips were treated with CD + BMAC.
METHODS: 39.8% cases worsened from stage 3 to stage 4, while the overall incidence of THR in stages 3 and 4 was 38.3%. On comparison with CD alone the combination of CD + BMAC did not show any enhanced efficacy in either delaying progression (Odds ratio of 1.41 (95% CI = 0.55-3.62) or in conversion to THR (Odds Ratio: 0. 92; 95% CI = 0.41-2.06).
CONCLUSIONS: CD can be considered in stage 3 of AVN in younger population to delay the need of arthroplasty, before severe head distortion and arthritis sets in, and can be supplemented with bone strut grafts or tantalum rods, for supporting the articular cartilage. BMAC that has shown better results in early AVN, has not shown any additional benefits when compared to CD alone in advanced cases.

BACKGROUND: Core decompression (CD) is effective in relieving pain and delaying the progression to total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH). However, the influence of CD on subsequent THA has not yet been established. Therefore, we performed this systematic review to answer: does prior CD have detrimental effect on subsequent THA for ONFH, especially with regards to survivorship and functional results, as well as perioperative and postoperative complications.
METHODS: After registration on PROSPERO (CRD42019118861), literature published up to and including November 2018 was searched in the PubMed, Embase and Cochrane library databases with predetermined terms. Comparative studies on the clinical outcomes between conversion to THA with prior CD (the Prior CD group) and primary THA (the Control group) for ONFH were included. The outcomes of interest included survivorship free from revision, the postoperative functional performance, perioperative and postoperative complications. Data was extracted systematically and a meta-analysis was performed.
RESULTS: Overall, 5 retrospective cohort studies with 110 hips were identified for the Prior CD group and 237 hips were identified for inclusion in the Control group. All of the studies were of high quality in terms of the Newcastle-Ottawa Scale. No difference in the rate of revision between the two groups (2/42 (4.8%) vs. 4/160 (2.5%); RR=1.92; 95% CI=0.34 to 10.75; p=0.46) was detected after a minimum two-year follow-up. The mean postoperative Harris Hip Score was similar between the two groups in all 5 studies. The two groups experienced similar blood loss (Mean difference=12.17ml; 95% CI= -15.28 to 39.61ml; p=0.38). Moreover, intraoperative fracture was increased in the Prior CD group, though this did not reach statistical significance (3/31 (9.7%) vs. 0/55 (0.0%); RR=7.05; 95% CI=0.82 to 60.78; p=0.08). Similarly, osteolysis or radiolucent lines were more likely to occur in the Prior CD group without statistical significance (9/81 (11.1%) vs. 6/200 (3.0%); RR=3.14, 95% CI=0.98 to 10.06; p=0.05).
CONCLUSIONS: The present evidence indicated that prior CD does not detrimentally affect the survivorship nor hip scores of subsequent THA. Attention should be paid, however, to the potential for intraoperative fracture, postoperative osteolysis or radiolucent lines.
METHODS: III; systematic review and meta-analysis of level III retrospective comparative studies.

Background: Core decompression is a hip preserving surgical procedure that is used to treat avascular necrosis (AVN) of the femoral head. The eventual clinical and radiological outcome following this procedure is varied in literature. Also, the time to a total hip replacement (THR) from the index procedure and the percentage of patients subsequently undergoing a THR is controversial. Furthermore, there are multiple surgical methods along with multiple augmentation techniques and various classification and staging systems described. The purpose of this systematic review, therefore, is to analyse the outcomes following decompression only, excluding any augmentation techniques for non-traumatic AVN of the femoral head. Methods: This protocol is being developed in line with the PRISMA-P guidelines. The search strategy includes articles from Medline, Embase, Google Scholar, CINHAL and Cochrane library. The review and screening will be done by two independent reviewers. Review articles, editorials and correspondences will be excluded. Articles including patients with sickle cell disease and with core decompression where augmentation is used will be excluded. The risk of bias and quality of articles will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for the different study designs included. Discussion: This study will be a comprehensive review on all published articles having patients with AVN of the femoral head and undergoing core decompression surgery only. The systematic review will then define the outcomes of the core decompression surgery based on clinical and radiological outcomes. Each outcome will include the different stages within it and finally, the total mean time to THR will be calculated. This will then be followed by assessing the cumulative confidence in evidence from all the data collected using the GRADE tool.   Registration: This systematic review is registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number:  CRD42018100596.