➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head Cite this article: Bone Joint J 2017;99-B:1267-79

An evidence-based guide to the treatment of osteonecrosis of the femoral head

Introduction Osteonecrosis of femoral head (ONFH) leads to hip osteoarthritis (HOA); among joint preserving treatments (JPT), the role of core decompression (CD) is still debated We assessed the efficacy of CD compared with all other JPT in delaying the natural osteonecrosis evolution to HOA Sources of data Following the PRISMA checklist, the Medline and Scopus databases were searched Fifteen- to 70-year-old subjects with ONFH with a minimum follow-up of 24 months were considered The outcomes evaluated were patient clinical status, radiographic progression and total hip arthroplasty (THA) or further surgery (FS) need Risk ratio (RR) was calculated for every outcome reported RCT, CCT and prospective studies were included Areas of agreement A total of 12 studies (776 patients) met the inclusion criteria Clinical outcome (RR = 114; 95% CI 058-232; P = 005), radiographic progression (RR = 164; 95% CI 114-235; P = 005) and the need for THA/FS (RR = 152; 95% CI 095-245; P = 005) suggested a slight superiority of other JPT compared with CD Areas of controversy High heterogeneity of the primary investigations was the main limitation of our study Growing points The efficacy and effectiveness of core decompression for ONFH are, at best, no better than other joint preserving strategies The more recent scientific evidence seems to suggest that such procedure is less successful than other joint preserving strategies Areas timely for developing research Further studies are needed to identify the best therapeutic approach to the ONFH

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Core decompression versus other joint preserving treatments for osteonecrosis of the femoral head: a meta-analysis.

Pulsed electromagnetic field (PEMF) stimulation, as a prospective, noninvasive, and safe physical therapy strategy to accelerate bone repair has received tremendous attention in recent decades. Physical PEMF stimulation initiates the signaling cascades, which effectively promote osteogenesis and angiogenesis in an orchestrated spatiotemporal manner and ultimately enhance the self-repair capability of bone tissues. Considerable research progresses have been made in exploring the underlying cellular and subcellular mechanisms of PEMF promotion effect in bone repair. Moreover, the promotion effect has shown strikingly positive benefits in the treatment of various skeletal diseases. However, many preclinical and clinical efficacy evaluation studies are still needed to make PEMFs more effective and extensive in clinical application. In this review, we briefly introduce the basic knowledge of PEMFs on bone repair, systematically elaborate several key signaling pathways involved in PEMFs-induced bone repair, and then discuss the therapeutic applications of PEMFs alone or in combination with other available therapies in bone repair, and evaluate the treatment effect by analyzing and summarizing recent literature.

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Underlying Signaling Pathways and Therapeutic Applications of Pulsed Electromagnetic Fields in Bone Repair.

Over the past three decades, non-vascularized bone grafts have been demonstrated to be viable treatments for pre- and early post-collapse osteonecrosis of the femoral head; however, there are limited reviews on this topic. Therefore, the purposes of this review are to (1) provide a summary of the different surgical techniques and their respective clinical outcomes and (2) evaluate new adjunct therapies. Originally, non-vascularized bone grafting was performed using the Phemister technique with varying results. More recently, newer techniques such as the lightbulb and trapdoor are used to place non-vascularized bone grafts with excellent results. The addition of various biological agents has demonstrated positive results; however, further studies are needed to confirm the best appropriate indications and to elucidate long-term results.

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A current review of non-vascularized bone grafting in osteonecrosis of the femoral head.

Introduction: The purpose of this prospective cohort study was to compare the surgical treatment of non- ONFH in adulthood by curettage and bone grafting with treatment by curettage and bone grafting in combination with invasive electromagnetic field treatment using Magnetodyn ® . This was assessed by examining whether electromagnetic field treatment has a positive additive effect on the clinical parameters modified Harris Hip Score according to Haddad, Cook and Brinker, Merle d'Aubigne hip score and visual analogue scale, and on the subsequent need for treatment by total hip arthroplasty. Materials and Methodology: The prospective, non-randomised study included 35 patients with unilateral or bilateral osteonecrosis of the femoral head. These were divided into two groups according to the surgical treatment regime and assessed over a 12-month follow-up period. The study group (Group 1) comprised 19 patients (14 men and 5 women) with a total of 22 non-ONFH, who underwent minimally invasive curettage, bone grafting and electromagnetic field treatment (Magnetodyn ® ) by implantation of a bipolar induction screw. The control group (Group 2) comprised 16 patients (12 men and 4 women) with a total of 18 non-ONFH, who underwent minimally invasive curettage and bone grafting without Magnetodyn ® therapy. At the initial pre-operative examination and the 6 and 12-month follow-up, all patients were assessed by clinical examination and radiological monitoring, and by bilateral hip MRI. The clinical evaluation was based on the modified Harris Hip Score according to Haddad, Cook and Brinker, the Merle dAubigne hip score and the visual analogue scale (VAS). Results: At the time of follow-up, total hip arthroplasty (THA) had been performed in four patients in Group 1 (18%). In Group 2, four patients (22%) had received a THA (n.s.). Both procedures led to an improvement in the clinical scores (Harris Hip Score, Merle dAubigne score and VAS), although no significant difference was observed. Conclusion: The authors conclude that electromagnetic field treatment with Magnetodyn ® , using the special signal protocol applied here, as an adjunct to curettage and autologous bone grafting to treat non-ONFH, does not produce better clinical results and does not offer better prophylaxis for the avoidance of total hip arthroplasty over all ARCO stages.

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M. Wagner

Papers

Invasive Electromagnetic Field Treatment in Osteonecrosis of the Femoral Head: A Prospective Cohort Study