Efficacy of Small-Diameter Core Decompression with Platelet-Rich Plasma in Early Osteonecrosis of the Femoral Head: A Retrospective Study

Efficacy of Small-Diameter Core Decompression with Platelet-Rich Plasma in Early Osteonecrosis of the Femoral Head: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of Small-Diameter Core Decompression with Platelet-Rich Plasma in Early Osteonecrosis of the Femoral Head: A Retrospective Study Haiwei Tang, YaHao Lai, Enze Zhao, Kai Zhou, Gang Chen, Zongke Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5339366/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 4 You are reading this latest preprint version Abstract Background Osteonecrosis of the femoral head (ONFH) is a challenging condition, primarily affecting young and middle-aged individuals, which results in hip dysfunction and, ultimately, femoral head collapse. However, the comparative effectiveness of joint-preserving procedures, particularly in the early stages of ONFH, remains inconclusive. This study aims to evaluate the efficacy of a novel technique called small-diameter core decompression (CD) combined with platelet-rich plasma (PRP), for the treatment of early-stage ONFH. Methods Clinical data of 40 patients (51 hips) with pre-collapse stage ONFH were retrospectively analyzed. Nineteen patients (23 hips) underwent small-diameter CD (group A) and 21 patients (28 hips) received conventional CD (group B) and follow-up was conducted every 3 months. Hip radiographs (X-rays and MRI) were evaluated using various ONFH staging systems (Preserved Angles, ARCO, JIC, and CHFJ stages). X-rays were performed at each follow-up to assess femoral head collapse and the rate of total hip arthroplasty (THA). Additionally, the Visual Analogue Scale (VAS), Harris Hip Score (HHS), Charnley score, SF-36, Athens Insomnia Scale (AIS), and State-Trait Anxiety Inventory (STAI) were used to evaluate hip pain, function, quality of life, and psychological status. These assessments were conducted both preoperatively and at each follow-up visit. Results The mean follow-up duration in Group CD + PRP was 11.57 months, with a femoral head survivorship of 82.61%. One hip underwent THA 14 months after the novel procedure. In Group CD, with an average follow-up period of 11.32 months, femoral head survivorship was 60.71% (p = 0.111), and 2 hips required THA (p = 0.999). At the final follow-up, the VAS, stiffness, HHS and Charnley scores of the PRP group showed significant improvements compared to those of the CD group. Quality of life, anxiety and insomnia were also significantly improved in the PRP group compared to CD group. Conclusion The application of PRP following CD results in significant pain relief, improved short-term functional outcomes, and enhanced quality of life compared to CD alone. However, whether it hinders disease progression in early ONFH and reduces the conversion rate to THA and femoral head collapse remains uncertain. Further research with larger sample sizes and extended follow-up is needed to validate these preliminary findings. Osteonecrosis of the femoral head small-diameter drilling core decompression Platelet-rich plasma Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Osteonecrosis of the femoral head (ONFH), also known as avascular necrosis (AVN) of the femoral head or ischemic necrosis, is characterized by local death of osteocytes and bone marrow components and leads to hip joint pain and dysfunction 1 , 2 . As a prevalent and refractory orthopedics condition, ONFH imposes a significant economic burden globally 3 – 5 . Typically affecting males between the ages of 30 and 50, the disease progresses through localized necrosis and subsequent repair, resulting in structural changes to the femoral head that compromise its weight-bearing capacity and ultimately lead to collapse 6 , 7 . Once collapse occurs, the efficacy of treatment diminishes, often necessitating total hip arthroplasty (THA) to alleviate pain and restore function. 8 . Consequently, early diagnosis and intervention are crucial to preventing femoral head collapse and preserving hip function. The primary objectives in early-stage ONFH are to relieve pain and slow disease progression. However, treatment options for ONFH remain varied and controversial. Conservative treatments include pharmacological approaches aimed at increasing calcium absorption, preventing bone resorption, anticoagulation, and vasodilation. Additionally, extracorporeal shock wave and hyperbaric oxygen therapy frequently employed for early-stage ONFH with small lesions frequently employed for early-stage ONFH with small lesions 9 – 11 . In contrast, surgical intervention has been extensively documented to impede disease progression 12 – 14 . Research indicates that femoral head collapse may occur within 1 to 4 years in approximately 80% of patients who do not undergo surgery in the early stages 15 . In patients undergoing hip preservation surgery, the femoral head survival rate significantly improves 9 . One study reported a survival rate of 93 out of 120 hips after five years of follow-up following multiple drilling 16 . Similarly, transtrochanteric rotational osteotomy achieved an 88% survival rate over four years for 113 hips 17 . Furthermore, for individuals with laterally located necrosis, which presents a high risk of collapse, early surgery to preserve the hip is recommended 8 , 12 . In addition to delaying disease progression, surgical procedures can also relieve pain, enhance hip function and improve quality of life in patients with symptomatic early-stage ONFH 18 , 19 . Core decompression (CD) is currently the most commonly utilized surgical procedure for hip preservation. The primary rationale is to alleviate intramedullary pressure and enhance blood circulation, thereby promoting revascularization and osteogenesis at the affected site, and has already demonstrated a certain level of efficacy. 20 , 21 . It has been employed for more than 50 years and has proven to be more effective than conservative treatments 22 , 23 . However, its long-term outcomes require further verified. In an early study involving 1206 hips CD patients, Mont et al. found that the necrosis continued to progress in 36% of the cases following CD alone 22 . A 2019 meta-analysis indicated that the overall success rate of CD was approximately 65%, and argued that mere CD is insufficient to halt the progression of ONFH 13 . Additionally, traditional CD has some inherent flaws. For instance, due to the limitation of a single channel, CD often results in an inadequate decompression range, potentially leading to surgical failure 24 . Moreover, traditional CD requires an entry hole in the lateral cortex of the femur, making it invasive for the patient and potentially increasing the risk of subtrochanteric fractures 25 – 27 . After decompression, the decompression channel lacks bony structural support, which may result in persistent pain or even premature collapse. To improve the results, small-diameter CD is utilized to minimize invasiveness and achieve a more comprehensive decompression range. Additionally, regenerative medicine has garnered significant interest among researchers. Through the original channel of CD, various regenerative agents, including bone marrow aspirate concentrate (BMAC) and bone mesenchymal stem cells (BMSCs), are injected into the lesion site to improve bone regeneration and offer support after decompression, which has been report to show certain therapeutic effect 28 – 30 . However, BMAC is invasive for patients and its operation and preparation process are complex. Moreover, its quality is easily influenced by the donor’s age and the extraction sites 31 . These drawbacks limit its widespread application. Platelet-Rich Plasma (PRP), an autologous derivative of whole blood generated by centrifugation, releases various cytokines and growth factors that promote cell proliferation and angiogenesis, enhancing the natural healing process upon activation. This may potentially improve the efficacy of CD 32 . Platelet-derived growth factor (PDGF), transforming growth factor-b (TGF-b), insulin-like growth factor (IGF), vascular endothelial growth factor (VEGF), hepatocyte growth factor, endothelial growth factor, and platelet factor-4 are among the bioactive substances derived from platelets that regulate cellular processes, like mitogenesis, chemotaxis, angiogenesis, differentiation, and metabolism, to improve tissue regeneration 33 , 34 . Furthermore, research has demonstrated that in the presence of bone morphogenetic proteins (BMP), such as BMP-2 or BMP-7, PRP can enhance the osteogenic differentiation of myoblasts and osteoblasts, thereby facilitating bone healing 35 . Compared with BMAC, PRP offers advantages of self-sufficiency, easier extraction and reduced trauma, making it widely applied in the treatment of chronic injury diseases 34 , 36 . However, only few clinical studies have been published on the use of PRP in in ONFH, and no definitive conclusions can be drawn regarding the therapeutic effect of CD combined with PRP 37 – 43 . Therefore, the present study aimed to evaluate whether CD combined with PRP could delay the progression of early-stage osteonecrosis of the femoral head. The primary objective included femoral head collapse rate, THA conversion rate, hip function and pain severity. Secondary observations included patients' quality of life, sleep, and anxiety. In addition, multiple small-diameter core decompression, a novel approach, were employed in this study to reduce invasiveness, achieve a more complete decompression range, and lower the risk of postoperative iatrogenic collapse 44 – 46 . We hypothesized that applying PRP after decompression would alleviate pain, improve functional outcome, and slow the progression of ONFH, thereby avoiding or delaying the need for THA. Patients and Methods We analyzed a consecutive series of patients at least 18 years old but no older than 80 years who underwent multiple small-diameter drilling CD plus PRP (group A) or traditional CD (group B) at our center between January 2022 and January 2024, who was diagnosed with early ONFH (ARCO stage I or II). The study was approved by the Ethics Committee on Biomedical Research of our medical center (Approval 2024 − 348) and designed in accordance with the Declaration of Helsinki, which waived the need for written informed consent because patients or their legal guardians, at the time of admission, signed written consent for patients’ anonymized data to be analyzed and published for research purposes. Inclusion criteria were: 1) patients with ARCO stage I or II of ONFH; 2) treatment with CD or CD combined with PRP in our hospital; 3) age ranged from 18 to 80 years; 4) those willing and able to return for follow-up during at least 6 months after procedure. Exclusion criteria were: 1) participants with collapsed stage ONFH; 2) had undergone hip preservation surgery other than CD; 3) bone marrow suppression, comorbidities such as pregnancy, cancer, and immunosuppression; 4) ONFH due to joint inflammatory disease or trauma. Patient demographic data were recorded and all demographic data of the patients are included in Table 1 . All patients underwent X-ray and MRI examinations preoperatively. Distinct staging criteria were employed for preoperative assessment based on the necrotic area and location of necrotic lesions observed on the coronal plane of the MRI (2019ARCO, 2021ARCO 47 , JIC and CHFJ stage) by two specialists. If the opinions of two experts are different, we will intervene in the third expert’s staging opinion, so as to complete the preoperative staging of patients. Moreover, we measured the Lateral Preserved Angle (LPA) of each hip on the X-ray, which weas defined by two lines extending from the center of the femoral head with the first passing through the lateral boundary of the necrotic lesion and the second passing through the point on the junction between the femoral head and the neck, and was considered as a simple method to predict collapse in early ONFH 8 . The details of staging systems and progression status were showed in Table 1 . Before surgery and at each follow-up we used Visual Analogue Scale (VAS), Harris Hip score (HHS), Charnley score, SF-36, Athens Insomnia Scale (AIS), and State-trait anxiety inventory (STAI) to assess hip pain, function, quality of life, and psychological status of patients. Table 1 Characteristic data of the patients. Characteristics Group PRP Group CD p Patients (Female/male) 19 (2/17) 21 (4/17) 0.664 Hips 23 28 - Side (R/L) 13/10 14/14 0.780 Age (years) 46.58 (7.46) 45.19 (10.61) 0.638 BMI (kg/m 2 ) 24.19 (2.25) 23.96 (2.32) 0.752 Follow-up (months) 11.57 (4.66) 11.32 (5.56) 0.868 Etiology of necrosis 0.114 Alchol abuse 6 (26.09%) 14 (50.00%) Corticosteroid use 3 (13.04%) 5 (17.86%) idiopathic 14 (60.87%) 9 (32.14%) ARCO 0.999 Type-I 3 (13.04%) 4 (14.29%) Type-II 20 (86.96%) 24 (85.74%) 2021ARCO 0.787 Type-1 1 (4.35%) 2 (7.14%) Type-2 6 (26.09%) 9 (32.14%) Type-3 16 (69.57%) 17 (60.71%) JIC 0.787 Type-A 1 (4.35%) 2 (7.14%) Type-B / / Type-C1 6 (26.09%) 9 (32.14%) Type-C2 16 (69.57%) 17 (60.71%) CHFJ 0.645 Type-C 1 (4.35%) 2 (7.14%) Type-L1 19 (82.61%) 20 (71.43%) Type-L2 / / Type-L3 3 (13.04%) 6 (21.43%) LPA 52.56 (37.87) 49.23 (24.56) 0.711 VAS (move) 4.09 (0.90) 4.05 (0.86) 0.825 VAS (rest) 2.26 (0.75) 2.14 (0.96) 0.584 VAS (sleep) 2.00 (1.24) 2.10 (0.89) 0.629 Stiffness (wake up) 2.32 (0.89) 2.43 (1.12) 0.662 Stiffness (rest) 1.54 (1.22) 1.67 (0.73) 0.436 HHS 65.88 (8.01) 66.26 (7.36) 0.861 Charnley 12.69 (1.67) 12.81 (1.47) 0.713 SF-36 PF 50.00 (12.85) 52.38 (14.11) 0.448 RP 40.91 (32.16) 42.86 (25.76) 0.828 BP 55.00 (16.80) 56.24 (13.44) 0.677 GH 60.27 (18.33) 62.43 (13.71) 0.479 VT 78.64 (7.78) 79.52 (8.79) 0.650 SF 60.61 (19.50) 62.04 (18.57) 0.790 RE 72.73 (29.14) 71.97 (18.14) 0.850 MH 67.64 (20.90) 66.48 (14.97) 0.725 HT 29.09 (10.44) 30.24 (11.45) 0.651 PCS 51.55 (17.92) 53.48 (19.35) 0.746 MCS 69.91 (18.23) 70.00 (16.37) 0.987 AIS 3.09 (2.43) 2.71 (1.76) 0.341 STAI S-AI 36.27 (6.59) 34.10 (6.34) 0.132 T-AI 32.27 (7.88) 31.62 (4.92) 0.551 BMI, body mass index; VAS, Visual Analogue Scale; HHS, Harris Hip Score; SF-36, 36-Item Short Form Survey; PF, Physical Functioning; RP, Role-Physical; BP, Bodily Pain; GH, General health; VT, validity; SF, Social Function; RE, Role-emotional; MH, Mental Health; PCS, Physical Component Summary; MCS, Mental Component Summary; AIS, Athens Insomnia Scale; STAI, State-trait Anxiety Inventory; S-AI, State Anxiety Inventory; T-AI, Trait Anxiety Inventory. Procedure A table-top centrifuge was used to prepare 50 milliliters of the patient's blood, which was then collected, centrifuged for 15 minutes at 1500 rpm, and then passed through a leukocyte filter (Imugard IIIPL; Terumo Penpol Co). Five milliliters of PRP were then injected into each hip. Complete aseptic precautions were taken during the entire surgery. The 4:1 ratio of calcium chloride needed for activation was administered using a different syringe. PRP culture and sensitivity were used to verify sterility. All the patients were operated by the same senior doctor in our hospital. In group CD + PRP, the patient laid flat with mild abduction and internal rotation of the affected limb and flexion, abduction and external rotation of the contralateral lower limb. After routine disinfection, a small incision (1cm) was made in front of the top of the greater trochanter of the hip on the affected side. After entering the joint, the arthroscopic channel was established by expanding the cannula step by step. Combined with the results of preoperative X-ray and MRI, the location of the necrotic area was determined. A Kirchner needle with a diameter of 1.5mm was used and fan decompression was performed from the anterolateral part of the head and neck junction to the necrotic area under the supervision of arthroscopy. After decompression, 5ml autologous PRP was injected along the borehole passage. In group CD, under C-arm X-ray guidance combined with preoperative X-ray and MRI, the necrotic area was precisely localized and the drilling direction, position, and depth were meticulously determined. From 2 cm below the greater trochanter of the femur, an 8 mm diameter Kirschner needle was then drilling into the osteonecrotic region for decompression. After surgery, isometric exercises were performed immediately. Then, as soon as the pain is tolerable, both passive and active hip movements are performed. On the second day following surgery, all patients began using crutches to walk; first non-weight-bearing and then gradually fully weight-bearing after 4–6 weeks. All patients were first followed up 1 month after surgery and then every 3 months after surgery. MRI was performed during at least 6 months of follow-up and to reassess whether ONFH progress. The endpoint was defined as underwent total hip arthroplasty (THA) or progressed to collapse. The results were then statistically analyzed. Statistical Analysis SPSS (version 29.0.1.0) was used to analyze the data. All quantitative variables were estimated using measures of central location (mean and median) and measures of dispersion (standard deviation 48 and standard error). Normality of data was checked by measures of skewness and Kolmogorov-Smirnov tests of normality. For normally distributed data, means were compared using Student t test for 2 groups. For more than 2 groups, analysis of variance was applied. For skewed data, Mann-Whitney test was applied. Intergroup differences in categorical variables were assessed for significance using the Pearson’s chi-squared test. All statistical tests were 2-sided and performed at a significance level of α = 0.05. Results There were 17 male and 2 female (23 hips) in group PRP, and 17 male and 4 female (28 hips) in group CD ( p = 0.664). An average age of the two groups were 46.58 (7.46) and 45.19 (10.61) respectively ( p = 0.638). A total of 20 patients presented with a history of alcoholism, 8 patients had previously utilized cortisol, and 23 patients were classified as idiopathic. No statistically significant differences in etiology were observed between the two groups ( p = 0.114). Furthermore, no significant differences in preoperative stage, hip function score, pain and SF-36 score between the two groups. The mean follow-up of the patients was 11.57 months in group PRP and 11.32 months in group CD (Table 1 ). No mortality occurred, either in the postoperative period or during follow-up. No patient was lost to follow-up for any reason. Radiologic Result In group PRP, with a mean follow-up time of 11.57 months, 4 out of 23 hips collapse occurred at 6, 9, 12 and 14 months postoperatively, respectively. In the remaining 19 hips, no significant signs of disease progression on imaging, with the longest follow-up period was 14 months. Whereas in group CD, 11 hips progressed to collapse in the last follow-up ( p = 0.111). None of the hip operated at stage I showed progression. One hip underwent THA at 14 months in group PRP and 2 hips in group CD underwent THA at 8 months and 18 months, respectively ( p = 0.999). At the final follow-up, the mean LPA improved from 50.00 (37.16) to 50.57 (35.87) in group PRP. In group CD the mean LPA decreased from 44.46 (20.62) to 40.47 (19.43). On comparing these two groups, there was no statistically significant difference in LPA ( p = 0.212) (Table 2 ) (Fig. 1 and Fig. 2 ). Table 2 Different stage of hips and progression in Group PRP and Group CD. Classification system Group PRP N (%) Postoperation 3m Group CD N (%) Postoperation 3m p Group PRP N (%) Postoperation 6m Group CD N (%) Postoperation 6m p Group PRP N (%) Last Follow-up Group CD N (%) Last Follow-up p Progress to collapse ARCO Type-I 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 Type-II 0 (0) 2 (8.33) 0.493 1 (5.00) 5 (20.83) 0.198 4 (20.00) 11 (45.83) 0.111 2021ARCO Type-1 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 Type-2 0 (0) 0 (0) 0.999 0 (0) 2 (22.22) 0.486 1 (16.67) 3 (33.33) 0.604 Type-3 0 (0) 2 (11.76) 0.485 1 (6.25) 3 (17.64) 0.601 3 (18.75) 8 (47.06) 0.141 JIC Type-A 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 Type-B / / / / / / / / / Type-C1 0 (0) 0 (0) 0.999 0 (0) 2 (22.22) 0.486 1 (16.67) 3 (33.33) 0.604 Type-C2 0 (0) 2 (11.76) 0.485 1 (6.25) 3 (17.64) 0.601 3 (18.75) 8 (47.06) 0.141 CHFJ Type-C 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 Type-L1 0 (0) 0 (0) 0.999 0 (0) 3 (15.00) 0.231 3 (15.79) 7 (35.00) 0.273 Type-L2 / / / / / / / / / Type-L3 0 (0) 2 (33.33) 0.500 1 (33.33) 2 (33.33) 0.999 1 (33.33) 4 (66.67) 0.524 LPA 52.33 (37.34) 48.87 (25.42) 0.701 51.97 (38.72) 45.37 (21.78) 0.452 50.57 (35.87) 40.47 (19.43) 0.212 THA conversion rate 0 (0) 0 (0) 0.999 0 (0) 0 (0) 0.999 1 (4.35) 2 (7.14) 0.999 ARCO, Association Research Circulation Osseous; JIC, Japanese Investigation Committee; CHFJ, China-Japan Friendship Hospital Clinical Results In terms of hip pain and functional scores, comparison of mean preoperative pain score, stiffness score and HHS between these two groups showed no statistically significant difference ( p > 0.05). At the 6-month post-operation and final follow-up, VAS scores in group PRP were significantly lower than those observed in group CD, with values of 2.05 (0.74) and 1.81 (0.51) for group PRP compared to 2.57 (0.68) and 2.42 (0.72) for group B ( p < 0.05), respectively. This disparity was also significant when resting or sleeping at the last follow-up ( p < 0.05). Similarity, there was a significant improvement in hip stiffness when, at the final follow-up, with values of 0.45 (0.67) and for group PRP compared to 0.88 (0.58) for group CD ( p = 0.020), respectively. Regarding the HHS score, group PRP demonstrated a significantly higher score compared to group CD at every postoperative follow-up. The scores recorded were 82.84 (11.36) and 76.17 (9.56) at 3 months follow-up ( p = 0.042), 85.88 (9.37) and 78.04 (5.14) at 6 months follow-up ( p = 0.001), and 87.76 (10.53) and 79.46 (7.13) at the last follow-up assessment ( p = 0.002). However, the Charnley score exhibited a consistent trend with HHS score only at 6 months follow-up 49 (Fig. 3 and Fig. 4 ). In secondary outcomes, the SF-36 revealed statistically significant improvements in 6 of its 9 aspects (PF, BP, GH, SF, MH, HT) at 6 months post-operation and 5 of 9 aspects (BP, GH, SF, MH, HT) at the last follow-up. However, the Physical Component Summary (PCS) demonstrated statistically significant differences solely at the final follow-up, with values of 72.01 (11.47) compared to 64.99 (12.23) ( p = 0.047). In contrast, the Mental Component Summary (MCS) did not exhibit substantial difference at the last follow-up. During anxiety assessments, the S-AI and T-AI scores of group PRP were significantly superior to those of group CD at the time point of our follow-up assessment. Out of all the aforementioned scale scores, only RE in the two groups does not meet the minimum clinically important difference (MCID) 50 , 51 , which means these two groups demonstrated improvements in pain, hip function, quality of life, and psychological status. And the PRP group showed greater effectiveness in these aspects (Table 3 ) (Fig. 5 ). Table 3 Score of different scales in group PRP and group CD. Description Postoperation (3m) (Group PRP) Postoperation (3m) (Group CD) p Postoperation (6m) (Group PRP) Postoperation (6m) (Group CD) p Postoperation (Last Follow-up (Group PRP) Postoperation (Last Follow-up) (Group CD) p MCID (Group PRP) MCID (Group CD) VAS (move) 2.54 (0.98) 2.98 (0.83) 0.096 2.05 (0.74) 2.57 (0.68) 0.021 1.81 (0.51) 2.42 (0.72) 0.002 0.45 0.43 VAS (rest) 0.68 (0.76) 0.97 (0.82) 0.213 0.48 (0.60) 0.81 (0.68) 0.100 0.38 (0.50) 0.74 (0.56) 0.024 0.38 0.48 VAS (sleep) 0.62 (0.77) 0.95 (0.74) 0.136 0.57 (0.60) 0.91 (0.66) 0.070 0.43 (0.60) 0.82 (0.57) 0.025 0.62 0.45 Stiffness (wake up) 0.83 (1.07) 1.18 (1.23) 0.303 0.77 (1.19) 1.03 (1.01) 0.413 0.45 (0.67) 0.88 (0.58) 0.020 0.46 0.56 Stiffness (rest) 0.67 (0.77) 1.06 (0.92) 0.123 0.59 (0.80) 0.86 (0.77) 0.256 0.55 (0.91) 0.96 (0.75) 0.091 0.61 0.37 HHS 82.42 (11.36) 76.17 (9.56) 0.042 85.88 (9.37) 78.04 (5.14) 0.001 87.76 (10.53) 79.46 (7.13) 0.002 4.01 3.68 Charnley 14.73 (1.88) 13.89 (1.56) 0.094 15.13 (1.74) 14.23 (1.23) 0.036 15.44 (1.98) 14.41 (1.67) 0.054 0.84 0.74 SF-36 PF 69.56 (13.87) 64.35 (13.27) 0.189 71.36 (14.51) 66.38 (12.11) 0.047 74.57 (13.24) 67.21 (12.39) 0.052 6.43 7.06 RP 58.38 (22.98) 54.28 (24.76) 0.557 59.09 (23.11) 56.65 (22.13) 0.703 62.33 (24.52) 55.28 (24.76) 0.327 16.08 12.88 BP 69.34 (7.72) 65.88 (8.36) 0.145 72.55 (6.27) 68.24 (7.38) 0.031 74.23 (7.83) 68.84 (8.54) 0.028 8.40 6.72 GH 77.53 (13.78) 69.72 (11.68) 0.037 78.32 (14.64) 70.83 (10.34) 0.038 76.89 (13.29) 68.61 (12.22) 0.025 9.16 6.86 VT 85.74 (5.63) 84.21 (6.68) 0.401 87.09 (6.25) 84.33 (8.79) 0.212 86.33 (8.34) 82.67 (9.87) 0.164 3.39 4.40 SF 75.88 (8.45) 71.31 (10.47) 0.108 78.75 (9.10) 73.91 (8.02) 0.049 79.83 (10.33) 72.31 (12.78) 0.032 9.75 9.29 RE 73.89 (18.64) 73.32 (19.23) 0.918 75.76 (26.21) 74.12 (17.88) 0.792 76.92 (22.98) 73.32 (19.23) 0.545 14.57 9.07 MH 80.87 (8.35) 73.22 (8.93) 0.004 84.00 (6.69) 77.13 (7.76) 0.012 85.33 (7.98) 79.26 (8.93) 0.018 10.45 7.49 HT 44.45 (10.57) 39.29 (9.67) 0.082 47.73 (12.32) 40.44 (12.12) 0.039 51.28 (13.58) 43.12 (12.94) 0.038 5.22 5.73 PCS 68.70 (15.66) 63.56 (14.97) 0.249 70.33 (14.28) 65.53 (14.78) 0.304 72.01 (11.47) 64.99 (12.23) 0.047 8.96 9.68 MCS 79.10 (11.53) 75.52 (12.92) 0.320 81.40 (13.98) 77.37 (11.39) 0.322 82.10 (13.53) 76.89 (13.72) 0.192 9.16 8.19 AIS 1.21 (1.15) 1.56 (1.33) 0.340 1.00 (1.09) 1.32 (1.21) 0.331 0.78 (1.17) 1.28 (1.05) 0.123 1.22 0.88 STAI S-AI 28.37 (3.28) 29.51 (4.18) 0.307 26.27 (3.17) 28.67 (3.22) 0.010 25.88 (3.42) 28.37 (4.18) 0.031 3.30 3.17 T-AI 25.79 (2.48) 27.12 (3.76) 0.166 23.09 (1.97) 25.12 (2.88) 0.006 22.78 (2.66) 24.87 (3.76) 0.035 3.94 2.46 Discussion ONFH is a refractory disease that currently lacks effective joint-preserving procedure. Over the past 30 years, core decompression (CD) has been employed in the early stages (stages I and II) of ONFH to prevent subsequent collapse of the necrotic femoral head. However, whether it truly delay the nature course of ONFH remains a subject of long-standing debate. Recently, researchers have sought to integrate various regenerative agents with CD to enhance its efficacy. This study demonstrated limited evidence that CD combined with PRP could alter the natural course of ONFH, though it showed improved efficacy in pain relief, improved hip function and quality of life. Traditional CD is performed from below the greater trochanter of the affected hip, with decompression achieved through puncture using a long needle. It not only relieves pressure within the femoral head but also removes necrotic tissue However, its ability to slow disease progression remains controversial. Hua et al. analyzed 1,379 hip joints treated solely with CD and found an overall success rate of 65%, with significant variations across different stages 13 . Zhu et al. analyzed 768 patients who underwent CD alone, finding a disease progression rate of 36% 52 . Additionally, the relatively large diameter of the Kirschner needle used may increase the risk of subtrochanteric femoral fractures post-surgery. Additionally, the use of relatively large-diameter of the Kirschner needle increase the risk of subtrochanteric femoral fractures after surgery 26 , 27 , 53 . Smith et al. reported that the femoral neck fracture rate during surgery and the early postoperative period was as high as 13% 54 . Therefore, traditional continuous drainage techniques require further refinement. One improved technique involves using small-diameter CD to reduce the fracture rate and expand the range of decompression 45 . Brown et al. demonstrated that small-diameter CD can improve femoral neck stability compared to single large-diameter CD procedures 44 . Mont et al. used 3mm diameter fine needles for decompression in 45 hips, and after a mean follow-up period of two years, 32 hips (71%) showed good to excellent HHS results 55 . However, whether it truly alters thenatural course of ONFH remains debate 13 , 56 , 57 . Mohanty et al. compared the efficacy of porous small diameter CD with autologous fibula grafting, and found that the three-year survival rate for the former was significantly lower than that for the latter 24 . To further enhance the femoral head survival rate in patients with, regenerative agents or cell therapies such as BMAC and BMSCshave garneredsubstantial attention. Li et al. analyzed 11 RCTS and 7 retrospective studies with a total of 1,257 hip joints, finding that stem cell therapy combined with CD was more effective in preventing collapse and radiological progression 58 . Piuzzi et al. reviewed the literatures to evaluate the benefits of cell-based therapy, concluding that suchcell therapies improves clinical outcomes 59 . However, due to the diversity of regenerative agents and the heterogeneity of studies necessitate further verification of their efficacy. Wang et al. performed a network meta-analysis to evaluate the efficacy of 6 different regenerative therapies for ONFH, finding that only BMAC and BMSCs delayed the disease’s natural course 29 . Nevertheless, the varying therapeutic efficacy, optimal injection concentration, and the effectivenessof allogeneic MSCs remains unresolved 31 , 60 . Additionally, the significant trauma,, difficult preparation process, and ethical concerns associated with BMAC and BMSCs limit their clinical application. Thus, regeneration agents that are easy to prepare, readily available, and have stable therapeutic efficacy are needed. Exosomes are small vesicles secreted by cells, with diameters ranging from 40 to 160 nm, capable of transferring various bioactive molecules, including nucleic acids, proteins, and lipids, from donor to recipient cells, thereby mediating intercellular communication and molecular transpor 61 . Compared with stem cells, exosomes offer advantages such as lower immunogenicity and greater abundance, making them a therapeutic potential for ONFH 62 . However, few studies have been conducted in the field of ONFH. As an easily obtainable source of growth factors, PRP has g attracted considerable attention within the medical community over the past two decades 63 . This regenerative agent contains high levels of growth factors and cytokines, which have the potential to accelerate bone repair by promoting pyhsiologic healing. It has been used as an augmentation during sugery and may serve as a useful adjuvant 34 , 64 , 65 . However, after an extensive review of the literature, only 7 studies were identified that focused on the use of PRP in the treatment of ONFH 37 – 43 . Three of these studies were case reports or case series 38 , 40 , 41 . Although these studies reported the potential benefits of PRP in patients with ONFH, they were considered to provide low-quality evidence due to the limited sample size. In other 3 studies, Houdek et al. assessed the efficacy of CD in combination with PRP and BMSCs 39 , whereas D'Ambrosi et al. used synthetic bone grafts for the treatment of ONFH after administrering PRP and BMSCs after CD 37 . Samy reported teh use of autologous bone graft combined with PRP after CD 42 . Although these studies have reported some efficacy of PRP, the specific role of PRP remains unclear due to the concurrent use of bone grafts and BMSCs. Only one RCT, conducted by Aggarwal et al., directly compared the efficacy between CD plus PRP ( 25 hips) with CD alone (28 hips). The rates of survivorship from femoral head collapse and THA was 84%/68% ( p < 0.001) and 92%/78% ( p = 0.010) in 2 groups, respectively, with a mean follow-up of 64 months, showing statistically significant results. 43 . The relatively small sample size of this study makes the role of PRP in the treatment of patients with early ONFH still unclear. In this study, no definitive conclusion can be drawn regarding the ability of PRP to delay the natural progression of ONFH. The reasons for this may be as follows: First, among these four collapsed hips, three were classified as 2021 ARCO type 3 or JIC type C2, with a mean LPA of 32.95°, indicating that the necrotic site involved weight-bearing areas, thereby presenting a high risk for collapse 8 , 47 . In addition, in 3 of the 4 patients, the contralateral hip joint had already collapsed, which, according to a 2021 study, could be a contributing factor to the collapse. The study indicated that symptomatic hip collapse influences the progression of ONFH in the contralateral hip, suggesting a potential interplay between the conditions of both hips 66 . This evidence suggests that these patients may be at a high risk for collapse. Second, the average age of our patients was higher than in the Aggarwal’s study, which may have contributed to the lower quality of the PRP 32 , 34 . This also may be the potential reason for the differing conclusions. Lastly, compared to the Aggarwal’s study, the follow-up period of our study is relatively short and may not have been sufficient to reveal the role of PRP in ONFH. Thus, although the LPA in group A was significantly higher than that in group B at the final follow-up, we cannot definitively conclude that PRP is effective in delaying disease progression. Future randomized controlled trials with larger sample sizes and longer follow-up periods are requiredto elucidate the role of PRP in ONFH. Regarding pain, stiffness and hip function score, group A showed significantly improved outcomes at the final follow-up, including the 4 collapsed hips, all of which reached MCID, indicating that PRP have a “symptom-modifying” effect. Meanwhile, although no difference between the two MCS groups at the last follow-up, the PRP group performed significantly better than the CD group in PCS, further reflecting PRP’s role in restoring physiological function. Furthermore, in group A, 5 patients had sleep difficulties before surgery, but by the final follow-up, their sleep quality had improved. Additionally,following surgery, the patients' anxiety levels significantly decreased. The above illustrated the short term effect of this technology on symptom relief. Despite the benefits of PRP, there remain several challenges in its clinical application. PRP can be classified into leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) based on their leukocyte concentration 67 . However, the precise cellular and clinical implications of these different PRP preparations remain unclear.Moreover, the lack of data on experimental specifics or the precise composition of the PRP formulations used presents a major obstacle to interpreting the PRP studies published to date 68 . This creates challenges for the practical application of PRP in orthopedics. There are several limitations in our study. Firstly, this was a retrospective study, which may introduce some bias and lead to inaccurate findings. Secondly, the short follow-up period of this study limit the reliability of the conclusions. Large sample RCTs are needed in the future to confirm the efficacy of PRP. Thirdly, during follow-up, we found that several patients in the PRP group continued smoking and drinking post-surgery, which led to postoperative pain and poorer imaging outcomes.. Therefore, postoperative behaviors r should be standardized in future studies. Finally, the extent of necrotic borders varied throughout patients, even though only those with early ONFH were included. Individuals who have an excessively small LPA Angle, JIC type C2, or 2021ARCO type 3 are already more likely to collapse, which may have an impact on the results, and future studies need to consider the impact of this factor. Conclusion In conclusion, compared to traditional CD, PRP has been shown to significantly alleviate pain, improve hip function and enhance quality of life. However, due to the limited follow-up time and relatively small sample size it remains uncertain whether this combination can enhance CD and slow the progression of ONFH. Large-scale randomized controlled trials (RCTs) are still necessary in the future to validate the effectiveness of this therapy. Declarations Funding Declarations The authors would like to thank the following funding sources: The National Key Research and Development Program of China (No. 2022YFC2503100 and 2022YFC2503104), National Natural Science Foundation of China (No. 82172394) and 1.3.5 project for disciplines of excellence, West China Hospital, University (No. ZYGD23033). Clinical Trial Number Not applicable. Ethics approval and consent to participate The study was approved by the Ethics Committee on Biomedical Research of our medical center (Approval 2024-348) and designed in accordance with the Declaration of Helsinki, which waived the need for written informed consent because patients or their legal guardians, at the time of admission, signed written consent for patients’ anonymized data to be analyzed and published for research purposes. Availability of data and materials Not applicable. Competing interests Not applicable. Provenance and peer review Not commissioned, externally peer-reviewed. Authors' Contributions Conceptualization: Haiwei Tang and Yahao Lai Investigation: Haiwei Tang, Enze Zhao and Yahao Lai Methodology: Gang Chen, Kai Zhou and Zongke Zhou Formal analysis: Haiwei Tang, Yahao Lai and Enze Zhao Writing – original draft: Haiwei Tang and Yahao Lai Writing – review & editing: Gang Chen and Zongke Zhou References Ando W, Sakai T, Fukushima W, et al. Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head. J Orthop Sci. 2021;26(1):46–68. https://doi.org/10.1016/j.jos.2020.06.013 . Wen Z, Li Y, Cai Z, et al. Global Trends and Current Status in Osteonecrosis of the Femoral Head: A Bibliometric Analysis of Publications in the Last 30 Years. Front Endocrinol (Lausanne). 2022;13:897439. https://doi.org/10.3389/fendo.2022.897439 . Ikeuchi K, Hasegawa Y, Seki T, Takegami Y, Amano T, Ishiguro N. Epidemiology of nontraumatic osteonecrosis of the femoral head in Japan. Mod Rheumatol. 2015;25(2):278–81. https://doi.org/10.3109/14397595.2014.932038 . Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am. 2015;97(19):1604–27. https://doi.org/10.2106/jbjs.O.00071 . Zhao DW, Yu M, Hu K, et al. Prevalence of Nontraumatic Osteonecrosis of the Femoral Head and its Associated Risk Factors in the Chinese Population: Results from a Nationally Representative Survey. Chin Med J (Engl). 2015;128(21):2843–50. https://doi.org/10.4103/0366-6999.168017 . Che Z, Song Y, Zhu L, Liu T, Li X, Huang L. Emerging roles of growth factors in osteonecrosis of the femoral head. Front Genet. 2022;13:1037190. https://doi.org/10.3389/fgene.2022.1037190 . Mont MA, Salem HS, Piuzzi NS, Goodman SB, Jones LC. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A 5-Year Update. J Bone Joint Surg Am. 2020;102(12):1084–99. https://doi.org/10.2106/jbjs.19.01271 . Wei QS, Li ZQ, Hong ZN, et al. Predicting Collapse in Osteonecrosis of the Femoral Head Using a New Method: Preserved Angles of Anterior and Lateral Femoral Head. J Bone Joint Surg Am. 2022;104(Suppl 2):47–53. https://doi.org/10.2106/jbjs.20.00507 . Chughtai M, Piuzzi NS, Khlopas A, Jones LC, Goodman SB, Mont MA. An evidence-based guide to the treatment of osteonecrosis of the femoral head. Bone Joint J. 2017;99–b(10):1267–79. https://doi.org/10.1302/0301-620x.99b10.Bjj-2017-0233.R2 . Lee YJ, Cui Q, Koo KH. Is There a Role of Pharmacological Treatments in the Prevention or Treatment of Osteonecrosis of the Femoral Head? A Systematic Review. J Bone Metab. 2019;26(1):13–8. https://doi.org/10.11005/jbm.2019.26.1.13 . Xie K, Mao Y, Qu X, et al. High-energy extracorporeal shock wave therapy for nontraumatic osteonecrosis of the femoral head. J Orthop Surg Res. 2018;13(1):25. https://doi.org/10.1186/s13018-017-0705-x . Kuroda Y, Tanaka T, Miyagawa T, et al. Classification of osteonecrosis of the femoral head: Who should have surgery? Bone Joint Res. 2019;8(10):451–8. https://doi.org/10.1302/2046-3758.810.Bjr-2019-0022.R1 . Hua KC, Yang XG, Feng JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res. 2019;14(1):306. https://doi.org/10.1186/s13018-019-1359-7 . Kuroda Y, Okuzu Y, Kawai T, Goto K, Matsuda S. Difference in Therapeutic Strategies for Joint-Preserving Surgery for Non-Traumatic Osteonecrosis of the Femoral Head between the United States and Japan: A Review of the Literature. Orthop Surg. 2021;13(3):742–8. https://doi.org/10.1111/os.12979 . Kaushik AP, Das A, Cui Q. Osteonecrosis of the femoral head: An update in year 2012. World J Orthop. 2012;3(5):49–57. https://doi.org/10.5312/wjo.v3.i5.49 . Song WS, Yoo JJ, Kim YM, Kim HJ. Results of multiple drilling compared with those of conventional methods of core decompression. Clin Orthop Relat Res. 2007;454:139–46. https://doi.org/10.1097/01.blo.0000229342.96103.73 . Ha YC, Kim HJ, Kim SY, Kim KC, Lee YK, Koo KH. Effects of age and body mass index on the results of transtrochanteric rotational osteotomy for femoral head osteonecrosis: surgical technique. J Bone Joint Surg Am. 2011;93(Suppl 1):75–84. https://doi.org/10.2106/jbjs.J.01215 . Karampinas P, Galanis A, Papagrigorakis E, et al. Osteonecrosis of the Femoral Head. Optimizing the Early-Stage Joint-Preserving Surgical Treatment? Maedica (Bucur). 2022;17(4):948–54. https://doi.org/10.26574/maedica.2022.17.4.948 . Osawa Y, Seki T, Okura T, Takegami Y, Ishiguro N, Hasegawa Y. Long-term outcomes of curved intertrochanteric varus osteotomy combined with bone impaction grafting for non-traumatic osteonecrosis of the femoral head. Bone Joint J. 2021;103–b(4):665–71. https://doi.org/10.1302/0301-620x.103b4.Bjj-2020-1107.R1 . Boontanapibul K, Huddleston JI 3rd, Amanatullah DF, Maloney WJ, Goodman SB. Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy. J Arthroplasty. 2021;36(6):1879–86. https://doi.org/10.1016/j.arth.2021.01.075 . Liu L, Gao F, Sun W, et al. Investigating clinical failure of core decompression with autologous bone marrow mononuclear cells grafting for the treatment of non-traumatic osteonecrosis of the femoral head. Int Orthop. 2018;42(7):1575–83. https://doi.org/10.1007/s00264-018-3918-7 . Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;324169–78. https://doi.org/10.1097/00003086-199603000-00020 . Stulberg BN, Davis AW, Bauer TW, Levine M, Easley K. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop Relat Res. 1991(268):140–151. DOI. Mohanty SP, Singh KA, Kundangar R, Shankar V. Management of non-traumatic avascular necrosis of the femoral head-a comparative analysis of the outcome of multiple small diameter drilling and core decompression with fibular grafting. Musculoskelet Surg. 2017;101(1):59–66. https://doi.org/10.1007/s12306-016-0431-2 . Hockett SA, Sherrill JT, Self M, Mears SC, Barnes CL, Mannen EM. Augmentation of core decompression with synthetic bone graft does not improve mechanical properties of the proximal femur. J Mech Behav Biomed Mater. 2021;115:104263. https://doi.org/10.1016/j.jmbbm.2020.104263 . Li S, Huang C, Wang W, et al. Subtrochanteric fracture after core decompression for osteonecrosis of the femoral head: a case report and literature review. BMC Musculoskelet Disord. 2024;25(1):420. https://doi.org/10.1186/s12891-024-07536-5 . Yuan D, Wu Z, Luo S, Zou Q, Zou Z, Ye C. Impact of Femoral Neck Cortical Bone Defect Induced by Core Decompression on Postoperative Stability: A Finite Element Analysis. Biomed Res Int. 2022;2022:3667891. https://doi.org/10.1155/2022/3667891 . Wang J, Xu P, Zhou L. Comparison of current treatment strategy for osteonecrosis of the femoral head from the perspective of cell therapy. Front Cell Dev Biol. 2023;11:995816. https://doi.org/10.3389/fcell.2023.995816 . Wang X, Hu L, Wei B, Wang J, Hou D, Deng X. Regenerative therapies for femoral head necrosis in the past two decades: a systematic review and network meta-analysis. Stem Cell Res Ther. 2024;15(1):21. https://doi.org/10.1186/s13287-024-03635-1 . Wang Z, Sun QM, Zhang FQ, Zhang QL, Wang LG, Wang WJ. Core decompression combined with autologous bone marrow stem cells versus core decompression alone for patients with osteonecrosis of the femoral head: A meta-analysis. Int J Surg. 2019;69:23–31. https://doi.org/10.1016/j.ijsu.2019.06.016 . Cavallo C, Boffa A, de Girolamo L, et al. Bone marrow aspirate concentrate quality is affected by age and harvest site. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2140–51. https://doi.org/10.1007/s00167-022-07153-6 . Su CA, Jildeh TR, Vopat ML, et al. Current State of Platelet-Rich Plasma and Cell-Based Therapies for the Treatment of Osteoarthritis and Tendon and Ligament Injuries. J Bone Joint Surg Am. 2022;104(15):1406–14. https://doi.org/10.2106/jbjs.21.01112 . Desouza C, Dubey R, Shetty V. Platelet-rich plasma in chronic Achilles tendinopathy. Eur J Orthop Surg Traumatol. 2023;33(8):3255–65. https://doi.org/10.1007/s00590-023-03570-6 . Rodeo SA, Orthobiologics. Current Status in 2023 and Future Outlook. J Am Acad Orthop Surg. 2023;31(12):604–13. https://doi.org/10.5435/jaaos-d-22-00808 . Tomoyasu A, Higashio K, Kanomata K, et al. Platelet-rich plasma stimulates osteoblastic differentiation in the presence of BMPs. Biochem Biophys Res Commun. 2007;361(1):62–7. https://doi.org/10.1016/j.bbrc.2007.06.142 . Noh KC, Liu XN, Zhuan Z, et al. Leukocyte-Poor Platelet-Rich Plasma-Derived Growth Factors Enhance Human Fibroblast Proliferation In Vitro. Clin Orthop Surg. 2018;10(2):240–7. https://doi.org/10.4055/cios.2018.10.2.240 . D'Ambrosi R, Biancardi E, Massari G, Ragone V, Facchini RM. Survival Analysis after Core Decompression in Association with Platelet-Rich Plasma, Mesenchymal Stem Cells, and Synthetic Bone Graft in Patients with Osteonecrosis of the Femoral Head. Joints. 2018;6(1):16–22. https://doi.org/10.1055/s-0038-1626740 . Guadilla J, Fiz N, Andia I, Sánchez M. Arthroscopic management and platelet-rich plasma therapy for avascular necrosis of the hip. Knee Surg Sports Traumatol Arthrosc. 2012;20(2):393–8. https://doi.org/10.1007/s00167-011-1587-9 . Houdek MT, Wyles CC, Collins MS, et al. Stem Cells Combined With Platelet-rich Plasma Effectively Treat Corticosteroid-induced Osteonecrosis of the Hip: A Prospective Study. Clin Orthop Relat Res. 2018;476(2):388–97. https://doi.org/10.1007/s11999.0000000000000033 . Ibrahim V, Dowling H. Platelet-rich plasma as a nonsurgical treatment option for osteonecrosis. Pm r. 2012;4(12):1015–9. https://doi.org/10.1016/j.pmrj.2012.07.009 . Pak J, Lee JH, Jeon JH, Lee SH. Complete resolution of avascular necrosis of the human femoral head treated with adipose tissue-derived stem cells and platelet-rich plasma. J Int Med Res. 2014;42(6):1353–62. https://doi.org/10.1177/0300060514546940 . Samy AM. Management of osteonecrosis of the femoral head: A novel technique. Indian J Orthop. 2016;50(4):359–65. https://doi.org/10.4103/0019-5413.185590 . Aggarwal AK, Poornalingam K, Jain A, Prakash M. Combining Platelet-Rich Plasma Instillation With Core Decompression Improves Functional Outcome and Delays Progression in Early-Stage Avascular Necrosis of Femoral Head: a 4.5- to 6-Year Prospective Randomized Comparative Study. J Arthroplasty. 2021;36(1):54–61. https://doi.org/10.1016/j.arth.2020.07.010 . Brown PJ, Mannava S, Seyler TM et al. Multiple Small Diameter Drillings Increase Femoral Neck Stability Compared with Single Large Diameter Femoral Head Core Decompression Technique for Avascular Necrosis of the Femoral Head. Surg Technol Int. 2016;29:247–254. DOI. Cilla M, Checa S, Preininger B, et al. Femoral head necrosis: A finite element analysis of common and novel surgical techniques. Clin Biomech (Bristol Avon). 2017;48:49–56. https://doi.org/10.1016/j.clinbiomech.2017.07.005 . Tan Y, He H, Wan Z, et al. Study on the outcome of patients with aseptic femoral head necrosis treated with percutaneous multiple small-diameter drilling core decompression: a retrospective cohort study based on magnetic resonance imaging and equivalent sphere model analysis. J Orthop Surg Res. 2020;15(1):264. https://doi.org/10.1186/s13018-020-01786-4 . Koo KH, Mont MA, Cui Q, et al. The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study. J Arthroplasty. 2022;37(6):1074–82. https://doi.org/10.1016/j.arth.2022.02.009 . Gausden EB, Qudsi R, Boone MD, OʼGara B, Ruzbarsky JJ, Lorich DG. Tranexamic Acid in Orthopaedic Trauma Surgery: A Meta-Analysis. J Orthop Trauma. 2017;31(10):513–9. https://doi.org/10.1097/bot.0000000000000913 . Charnley J. Charnley JJLfaotht, practice. Numerical grading of clinical results. 1979:20–24. DOI. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41(5):582–92. https://doi.org/10.1097/01.Mlr.0000062554.74615.4c . Yeo MGH, Goh GS, Chen JY, Lo NN, Yeo SJ, Liow MHL. Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty? J Arthroplasty. 2020;35(9):2458–64. https://doi.org/10.1016/j.arth.2020.04.034 . Zhu S, Zhang X, Chen X, Wang Y, Li S, Qian W. Comparison of cell therapy and other novel adjunctive therapies combined with core decompression for the treatment of osteonecrosis of the femoral head: a systematic review and meta-analysis of 20 studies. Bone Joint Res. 2021;10(7):445–58. https://doi.org/10.1302/2046-3758.107.Bjr-2020-0418.R1 . Yue J, Guo X, Wang R, et al. Preliminary report of the outcomes and indications of single approach, double-channel core decompression with structural bone support and bone grafting for osteonecrosis of the femoral head. BMC Musculoskelet Disord. 2022;23(1):198. https://doi.org/10.1186/s12891-022-05149-4 . Smith SW, Fehring TK, Griffin WL, Beaver WB. Core decompression of the osteonecrotic femoral head. J Bone Joint Surg Am. 1995;77(5):674–80. https://doi.org/10.2106/00004623-199505000-00003 . Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res. 2004;429131–8. https://doi.org/10.1097/01.blo.0000150128.57777.8e . Yoon BH, Lee YK, Kim KC, Ha YC, Koo KH. No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis. Int Orthop. 2018;42(12):2737–43. https://doi.org/10.1007/s00264-018-3977-9 . Sadile F, Bernasconi A, Russo S, Maffulli N. Core decompression versus other joint preserving treatments for osteonecrosis of the femoral head: a meta-analysis. Br Med Bull. 2016;118(1):33–49. https://doi.org/10.1093/bmb/ldw010 . Li M, Chen D, Ma Y, Zheng M, Zheng Q. Stem cell therapy combined with core decompression versus core decompression alone in the treatment of avascular necrosis of the femoral head: a systematic review and meta-analysis. J Orthop Surg Res. 2023;18(1):560. https://doi.org/10.1186/s13018-023-04025-8 . Piuzzi NS, Chahla J, Schrock JB, et al. Evidence for the Use of Cell-Based Therapy for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature. J Arthroplasty. 2017;32(5):1698–708. https://doi.org/10.1016/j.arth.2016.12.049 . Goodman SB, Maruyama M, Inflammation. Bone Healing and Osteonecrosis: From Bedside to Bench. J Inflamm Res. 2020;13:913–23. https://doi.org/10.2147/jir.S281941 . Kalluri R, LeBleu VS. The biology, function, and biomedical applications of exosomes. Science. 2020;367(6478). https://doi.org/10.1126/science.aau6977 . Xia L, Zhang C, Lv N, et al. AdMSC-derived exosomes alleviate acute lung injury via transferring mitochondrial component to improve homeostasis of alveolar macrophages. Theranostics. 2022;12(6):2928–47. https://doi.org/10.7150/thno.69533 . Dos Santos RG, Santos GS, Alkass N, et al. The regenerative mechanisms of platelet-rich plasma: A review. Cytokine. 2021;144:155560. https://doi.org/10.1016/j.cyto.2021.155560 . Fice MP, Miller JC, Christian R, et al. The Role of Platelet-Rich Plasma in Cartilage Pathology: An Updated Systematic Review of the Basic Science Evidence. Arthroscopy. 2019;35(3):961–e976963. https://doi.org/10.1016/j.arthro.2018.10.125 . Ruiz-Moneo P, Molano-Muñoz J, Prieto E, Algorta J. Plasma rich in growth factors in arthroscopic rotator cuff repair: a randomized, double-blind, controlled clinical trial. Arthroscopy. 2013;29(1):2–9. https://doi.org/10.1016/j.arthro.2012.08.014 . Osawa Y, Seki T, Takegami Y, Makida K, Ochiai S, Imagama S. Collapse Progression or Cessation Affects the Natural History of Contralateral Osteonecrosis of the Femoral Head. J Arthroplasty. 2021;36(12):3839–44. https://doi.org/10.1016/j.arth.2021.08.005 . Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med. 2018;11(4):624–34. https://doi.org/10.1007/s12178-018-9527-7 . Chahla J, Cinque ME, Piuzzi NS, et al. A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature. J Bone Joint Surg Am. 2017;99(20):1769–79. https://doi.org/10.2106/jbjs.16.01374 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 29 Oct, 2024 Editor assigned by journal 28 Oct, 2024 Submission checks completed at journal 28 Oct, 2024 First submitted to journal 26 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5339366","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371721557,"identity":"f9856843-fd27-4c57-827e-cd33fbb5b0ae","order_by":0,"name":"Haiwei Tang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Haiwei","middleName":"","lastName":"Tang","suffix":""},{"id":371721559,"identity":"5a9f1626-df17-40fb-87a6-991620d5d60e","order_by":1,"name":"YaHao Lai","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"YaHao","middleName":"","lastName":"Lai","suffix":""},{"id":371721560,"identity":"b8bd0028-d7ab-47cd-9cb6-a46a5f611558","order_by":2,"name":"Enze Zhao","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Enze","middleName":"","lastName":"Zhao","suffix":""},{"id":371721561,"identity":"d7dbb08b-7430-4334-8166-fe65bf202a3f","order_by":3,"name":"Kai Zhou","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Zhou","suffix":""},{"id":371721562,"identity":"4c197547-5743-4d5e-8eb7-debb8106abec","order_by":4,"name":"Gang Chen","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Gang","middleName":"","lastName":"Chen","suffix":""},{"id":371721563,"identity":"0c7547a1-ed37-4024-a3c3-44f88c79e8ff","order_by":5,"name":"Zongke Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACCTjNfADCOkC8FrYEkrXwGBCnRX528zHJHxV37Ga293z+8LONQY7vRgLj5wI8WhjnHEuTkDjzLHk2z9ltkr1tDMaSNxKYpWfg0cIskWMmYdh2OFlOIncbM2MbQ+KGGwlszDx4tLCBtCSCtMi/efwZqKWeoBYekJaDbYftpCV4GKSBWhIMCGmRkEhLtmw4czhBsifNTLLnnIThzDMPm6XxaZGfkXzw5o+Kw/YSxw8//vCjzEae73jywc/4tMBAYgPUViBmbCBCAwODPVGqRsEoGAWjYGQCAMdVSLG5Q8fDAAAAAElFTkSuQmCC","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Zongke","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2024-10-27 02:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5339366/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5339366/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-024-08243-x","type":"published","date":"2025-01-03T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68353668,"identity":"cd0a836d-aae6-4162-986c-d5c3cad77059","added_by":"auto","created_at":"2024-11-06 11:06:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":311506,"visible":true,"origin":"","legend":"\u003cp\u003e(A, C) Preoperative hip X-ray and MRI indicated ARCO II stage of femoral head necrosis. (B, D) X rays and magnetic resonance imaging at final follow-up of 12 months showing no significant progression of ONFH.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5339366/v1/0c2a8c259ca1ebf920e7e8bb.png"},{"id":68355133,"identity":"f84207b9-0c41-4c8c-9a4f-0e85ef93418a","added_by":"auto","created_at":"2024-11-06 11:14:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":386199,"visible":true,"origin":"","legend":"\u003cp\u003e(A, C) Preoperative hip X-ray and MRI indicated ARCO II stage of femoral head necrosis. (B, D) X rays and magnetic resonance imaging at final follow-up of 6 months showing no significant progression of ONFH.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5339366/v1/9c1d7b44cb9065d5e068f7c2.png"},{"id":68353665,"identity":"010fc071-e22b-485e-9674-6fecc06a6be9","added_by":"auto","created_at":"2024-11-06 11:06:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":48047,"visible":true,"origin":"","legend":"\u003cp\u003eGraph showing statistically significant improvement in pain and stiffness score in group CD + PRP as compared with group CD at 3 months (VAS: \u003cem\u003ep\u003c/em\u003e = 0.096, Stiffness: \u003cem\u003ep\u003c/em\u003e= 0.303), 6 months (VAS: \u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.021\u003c/strong\u003e, Stiffness: \u003cem\u003ep\u003c/em\u003e = 0.413), and final follow-up (VAS: \u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.002\u003c/strong\u003e, Stiffness:\u003cem\u003e \u003c/em\u003e\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.020\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5339366/v1/97ffac4682a96dfc008eb3c8.png"},{"id":68353664,"identity":"6a5239d7-5fe3-44c3-b8ea-d2fd1556f817","added_by":"auto","created_at":"2024-11-06 11:06:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":37796,"visible":true,"origin":"","legend":"\u003cp\u003eGraph showing statistically significant improvement in HHS score in group CD + PRP as compared with group CD at 3 months (\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.042\u003c/strong\u003e), 6 months (\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.001\u003c/strong\u003e), and final follow-up (\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.002\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5339366/v1/c07126e5f62a3a9db518e945.png"},{"id":68355132,"identity":"3aa7007c-452e-4fb7-9421-3f3cc0ee8341","added_by":"auto","created_at":"2024-11-06 11:14:37","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":46731,"visible":true,"origin":"","legend":"\u003cp\u003eDifferences in PCS and MCS score between group CD + PRP and group CD at 3 months (PCS: \u003cem\u003ep\u003c/em\u003e = 0.249, MCS: \u003cem\u003ep\u003c/em\u003e= 0.320), 6 months (PCS: \u003cem\u003ep\u003c/em\u003e = 0.304, MCS: \u003cem\u003ep\u003c/em\u003e = 0.322), and final follow-up (PCS: \u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e = 0.047\u003c/strong\u003e, MCS:\u003cem\u003e p\u003c/em\u003e = 0.192).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5339366/v1/6a5200a77967c7714084ed40.png"},{"id":73093220,"identity":"073a503b-1073-46a7-807e-7dbcc45699cf","added_by":"auto","created_at":"2025-01-06 16:11:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1880306,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5339366/v1/f0fd0a7d-8773-475c-a1eb-d315c860a66b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of Small-Diameter Core Decompression with Platelet-Rich Plasma in Early Osteonecrosis of the Femoral Head: A Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteonecrosis of the femoral head (ONFH), also known as avascular necrosis (AVN) of the femoral head or ischemic necrosis, is characterized by local death of osteocytes and bone marrow components and leads to hip joint pain and dysfunction\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. As a prevalent and refractory orthopedics condition, ONFH imposes a significant economic burden globally\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Typically affecting males between the ages of 30 and 50, the disease progresses through localized necrosis and subsequent repair, resulting in structural changes to the femoral head that compromise its weight-bearing capacity and ultimately lead to collapse\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Once collapse occurs, the efficacy of treatment diminishes, often necessitating total hip arthroplasty (THA) to alleviate pain and restore function.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Consequently, early diagnosis and intervention are crucial to preventing femoral head collapse and preserving hip function. The primary objectives in early-stage ONFH are to relieve pain and slow disease progression. However, treatment options for ONFH remain varied and controversial. Conservative treatments include pharmacological approaches aimed at increasing calcium absorption, preventing bone resorption, anticoagulation, and vasodilation. Additionally, extracorporeal shock wave and hyperbaric oxygen therapy frequently employed for early-stage ONFH with small lesions frequently employed for early-stage ONFH with small lesions\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In contrast, surgical intervention has been extensively documented to impede disease progression\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Research indicates that femoral head collapse may occur within 1 to 4 years in approximately 80% of patients who do not undergo surgery in the early stages\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In patients undergoing hip preservation surgery, the femoral head survival rate significantly improves\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. One study reported a survival rate of 93 out of 120 hips after five years of follow-up following multiple drilling\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Similarly, transtrochanteric rotational osteotomy achieved an 88% survival rate over four years for 113 hips\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Furthermore, for individuals with laterally located necrosis, which presents a high risk of collapse, early surgery to preserve the hip is recommended\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In addition to delaying disease progression, surgical procedures can also relieve pain, enhance hip function and improve quality of life in patients with symptomatic early-stage ONFH\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCore decompression (CD) is currently the most commonly utilized surgical procedure for hip preservation. The primary rationale is to alleviate intramedullary pressure and enhance blood circulation, thereby promoting revascularization and osteogenesis at the affected site, and has already demonstrated a certain level of efficacy.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. It has been employed for more than 50 years and has proven to be more effective than conservative treatments\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. However, its long-term outcomes require further verified. In an early study involving 1206 hips CD patients, Mont et al. found that the necrosis continued to progress in 36% of the cases following CD alone\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. A 2019 meta-analysis indicated that the overall success rate of CD was approximately 65%, and argued that mere CD is insufficient to halt the progression of ONFH\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Additionally, traditional CD has some inherent flaws. For instance, due to the limitation of a single channel, CD often results in an inadequate decompression range, potentially leading to surgical failure\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Moreover, traditional CD requires an entry hole in the lateral cortex of the femur, making it invasive for the patient and potentially increasing the risk of subtrochanteric fractures\u003csup\u003e\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. After decompression, the decompression channel lacks bony structural support, which may result in persistent pain or even premature collapse.\u003c/p\u003e \u003cp\u003eTo improve the results, small-diameter CD is utilized to minimize invasiveness and achieve a more comprehensive decompression range. Additionally, regenerative medicine has garnered significant interest among researchers. Through the original channel of CD, various regenerative agents, including bone marrow aspirate concentrate (BMAC) and bone mesenchymal stem cells (BMSCs), are injected into the lesion site to improve bone regeneration and offer support after decompression, which has been report to show certain therapeutic effect\u003csup\u003e\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. However, BMAC is invasive for patients and its operation and preparation process are complex. Moreover, its quality is easily influenced by the donor\u0026rsquo;s age and the extraction sites\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. These drawbacks limit its widespread application. Platelet-Rich Plasma (PRP), an autologous derivative of whole blood generated by centrifugation, releases various cytokines and growth factors that promote cell proliferation and angiogenesis, enhancing the natural healing process upon activation. This may potentially improve the efficacy of CD\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Platelet-derived growth factor (PDGF), transforming growth factor-b (TGF-b), insulin-like growth factor (IGF), vascular endothelial growth factor (VEGF), hepatocyte growth factor, endothelial growth factor, and platelet factor-4 are among the bioactive substances derived from platelets that regulate cellular processes, like mitogenesis, chemotaxis, angiogenesis, differentiation, and metabolism, to improve tissue regeneration\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Furthermore, research has demonstrated that in the presence of bone morphogenetic proteins (BMP), such as BMP-2 or BMP-7, PRP can enhance the osteogenic differentiation of myoblasts and osteoblasts, thereby facilitating bone healing\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Compared with BMAC, PRP offers advantages of self-sufficiency, easier extraction and reduced trauma, making it widely applied in the treatment of chronic injury diseases\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. However, only few clinical studies have been published on the use of PRP in in ONFH, and no definitive conclusions can be drawn regarding the therapeutic effect of CD combined with PRP\u003csup\u003e\u003cspan additionalcitationids=\"CR38 CR39 CR40 CR41 CR42\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to evaluate whether CD combined with PRP could delay the progression of early-stage osteonecrosis of the femoral head. The primary objective included femoral head collapse rate, THA conversion rate, hip function and pain severity. Secondary observations included patients' quality of life, sleep, and anxiety. In addition, multiple small-diameter core decompression, a novel approach, were employed in this study to reduce invasiveness, achieve a more complete decompression range, and lower the risk of postoperative iatrogenic collapse\u003csup\u003e\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. We hypothesized that applying PRP after decompression would alleviate pain, improve functional outcome, and slow the progression of ONFH, thereby avoiding or delaying the need for THA.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eWe analyzed a consecutive series of patients at least 18 years old but no older than 80 years who underwent multiple small-diameter drilling CD plus PRP (group A) or traditional CD (group B) at our center between January 2022 and January 2024, who was diagnosed with early ONFH (ARCO stage I or II). The study was approved by the Ethics Committee on Biomedical Research of our medical center (Approval 2024\u0026thinsp;\u0026minus;\u0026thinsp;348) and designed in accordance with the Declaration of Helsinki, which waived the need for written informed consent because patients or their legal guardians, at the time of admission, signed written consent for patients\u0026rsquo; anonymized data to be analyzed and published for research purposes.\u003c/p\u003e \u003cp\u003eInclusion criteria were: 1) patients with ARCO stage I or II of ONFH; 2) treatment with CD or CD combined with PRP in our hospital; 3) age ranged from 18 to 80 years; 4) those willing and able to return for follow-up during at least 6 months after procedure. Exclusion criteria were: 1) participants with collapsed stage ONFH; 2) had undergone hip preservation surgery other than CD; 3) bone marrow suppression, comorbidities such as pregnancy, cancer, and immunosuppression; 4) ONFH due to joint inflammatory disease or trauma. Patient demographic data were recorded and all demographic data of the patients are included in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All patients underwent X-ray and MRI examinations preoperatively. Distinct staging criteria were employed for preoperative assessment based on the necrotic area and location of necrotic lesions observed on the coronal plane of the MRI (2019ARCO, 2021ARCO\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e, JIC and CHFJ stage) by two specialists. If the opinions of two experts are different, we will intervene in the third expert\u0026rsquo;s staging opinion, so as to complete the preoperative staging of patients. Moreover, we measured the Lateral Preserved Angle (LPA) of each hip on the X-ray, which weas defined by two lines extending from the center of the femoral head with the first passing through the lateral boundary of the necrotic lesion and the second passing through the point on the junction between the femoral head and the neck, and was considered as a simple method to predict collapse in early ONFH\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The details of staging systems and progression status were showed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Before surgery and at each follow-up we used Visual Analogue Scale (VAS), Harris Hip score (HHS), Charnley score, SF-36, Athens Insomnia Scale (AIS), and State-trait anxiety inventory (STAI) to assess hip pain, function, quality of life, and psychological status of patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristic data of the patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup PRP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup CD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients (Female/male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (2/17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (4/17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide (R/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14/14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.780\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.58 (7.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.19 (10.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.19 (2.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.96 (2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.752\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.57 (4.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.32 (5.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEtiology of necrosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlchol abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (26.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (50.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorticosteroid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (17.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eidiopathic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (60.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (32.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eARCO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (14.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (86.96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (85.74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2021ARCO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (26.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (32.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (69.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (60.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJIC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-C1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (26.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (32.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-C2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (69.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (60.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCHFJ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-L1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (82.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (71.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-L3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (21.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLPA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.56 (37.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.23 (24.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS (move)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.09 (0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.05 (0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS (rest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.26 (0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.14 (0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS (sleep)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.00 (1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.629\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStiffness (wake up)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.32 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.43 (1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStiffness (rest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.54 (1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.67 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.88 (8.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.26 (7.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.861\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharnley\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.69 (1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.81 (1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSF-36\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.00 (12.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.38 (14.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.91 (32.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.86 (25.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.00 (16.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.24 (13.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.677\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.27 (18.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.43 (13.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.479\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.64 (7.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.52 (8.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.650\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.61 (19.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.04 (18.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.790\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.73 (29.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.97 (18.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.64 (20.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.48 (14.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.09 (10.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.24 (11.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.651\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.55 (17.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.48 (19.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.746\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.91 (18.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.00 (16.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.09 (2.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.71 (1.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSTAI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS-AI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.27 (6.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.10 (6.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT-AI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.27 (7.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.62 (4.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBMI, body mass index; VAS, Visual Analogue Scale; HHS, Harris Hip Score; SF-36, 36-Item Short Form Survey; PF, Physical Functioning; RP, Role-Physical; BP, Bodily Pain; GH, General health; VT, validity; SF, Social Function; RE, Role-emotional; MH, Mental Health; PCS, Physical Component Summary; MCS, Mental Component Summary; AIS, Athens Insomnia Scale; STAI, State-trait Anxiety Inventory; S-AI, State Anxiety Inventory; T-AI, Trait Anxiety Inventory.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eA table-top centrifuge was used to prepare 50 milliliters of the patient's blood, which was then collected, centrifuged for 15 minutes at 1500 rpm, and then passed through a leukocyte filter (Imugard IIIPL; Terumo Penpol Co). Five milliliters of PRP were then injected into each hip. Complete aseptic precautions were taken during the entire surgery. The 4:1 ratio of calcium chloride needed for activation was administered using a different syringe. PRP culture and sensitivity were used to verify sterility.\u003c/p\u003e \u003cp\u003eAll the patients were operated by the same senior doctor in our hospital. In group CD\u0026thinsp;+\u0026thinsp;PRP, the patient laid flat with mild abduction and internal rotation of the affected limb and flexion, abduction and external rotation of the contralateral lower limb. After routine disinfection, a small incision (1cm) was made in front of the top of the greater trochanter of the hip on the affected side. After entering the joint, the arthroscopic channel was established by expanding the cannula step by step. Combined with the results of preoperative X-ray and MRI, the location of the necrotic area was determined. A Kirchner needle with a diameter of 1.5mm was used and fan decompression was performed from the anterolateral part of the head and neck junction to the necrotic area under the supervision of arthroscopy. After decompression, 5ml autologous PRP was injected along the borehole passage.\u003c/p\u003e \u003cp\u003eIn group CD, under C-arm X-ray guidance combined with preoperative X-ray and MRI, the necrotic area was precisely localized and the drilling direction, position, and depth were meticulously determined. From 2 cm below the greater trochanter of the femur, an 8 mm diameter Kirschner needle was then drilling into the osteonecrotic region for decompression.\u003c/p\u003e \u003cp\u003eAfter surgery, isometric exercises were performed immediately. Then, as soon as the pain is tolerable, both passive and active hip movements are performed. On the second day following surgery, all patients began using crutches to walk; first non-weight-bearing and then gradually fully weight-bearing after 4\u0026ndash;6 weeks. All patients were first followed up 1 month after surgery and then every 3 months after surgery. MRI was performed during at least 6 months of follow-up and to reassess whether ONFH progress. The endpoint was defined as underwent total hip arthroplasty (THA) or progressed to collapse. The results were then statistically analyzed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eSPSS (version 29.0.1.0) was used to analyze the data. All quantitative variables were estimated using measures of central location (mean and median) and measures of dispersion (standard deviation\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e and standard error). Normality of data was checked by measures of skewness and Kolmogorov-Smirnov tests of normality. For normally distributed data, means were compared using Student t test for 2 groups. For more than 2 groups, analysis of variance was applied. For skewed data, Mann-Whitney test was applied. Intergroup differences in categorical variables were assessed for significance using the Pearson\u0026rsquo;s chi-squared test. All statistical tests were 2-sided and performed at a significance level of α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 17 male and 2 female (23 hips) in group PRP, and 17 male and 4 female (28 hips) in group CD (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.664). An average age of the two groups were 46.58 (7.46) and 45.19 (10.61) respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.638). A total of 20 patients presented with a history of alcoholism, 8 patients had previously utilized cortisol, and 23 patients were classified as idiopathic. No statistically significant differences in etiology were observed between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.114). Furthermore, no significant differences in preoperative stage, hip function score, pain and SF-36 score between the two groups. The mean follow-up of the patients was 11.57 months in group PRP and 11.32 months in group CD (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No mortality occurred, either in the postoperative period or during follow-up. No patient was lost to follow-up for any reason.\u003c/p\u003e\n\u003ch3\u003eRadiologic Result\u003c/h3\u003e\n\u003cp\u003eIn group PRP, with a mean follow-up time of 11.57 months, 4 out of 23 hips collapse occurred at 6, 9, 12 and 14 months postoperatively, respectively. In the remaining 19 hips, no significant signs of disease progression on imaging, with the longest follow-up period was 14 months. Whereas in group CD, 11 hips progressed to collapse in the last follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.111). None of the hip operated at stage I showed progression. One hip underwent THA at 14 months in group PRP and 2 hips in group CD underwent THA at 8 months and 18 months, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.999). At the final follow-up, the mean LPA improved from 50.00 (37.16) to 50.57 (35.87) in group PRP. In group CD the mean LPA decreased from 44.46 (20.62) to 40.47 (19.43). On comparing these two groups, there was no statistically significant difference in LPA (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.212) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferent stage of hips and progression in Group PRP and Group CD.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification system\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup PRP\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003ePostoperation 3m\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup CD\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003ePostoperation 3m\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup PRP\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003ePostoperation 6m\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGroup CD\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003ePostoperation 6m\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGroup PRP\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003eLast Follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGroup CD\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003eLast Follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProgress to collapse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eARCO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (20.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11 (45.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2021ARCO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (22.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.604\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (11.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (17.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (18.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8 (47.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-C1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (22.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.604\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-C2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (11.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (17.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (18.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8 (47.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHFJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-L1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (15.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (15.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7 (35.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType-L3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLPA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.33 (37.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.87 (25.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.97 (38.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.37 (21.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50.57 (35.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e40.47 (19.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTHA conversion rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eARCO, Association Research Circulation Osseous; JIC, Japanese Investigation Committee; CHFJ, China-Japan Friendship Hospital\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eClinical Results\u003c/h3\u003e\n\u003cp\u003eIn terms of hip pain and functional scores, comparison of mean preoperative pain score, stiffness score and HHS between these two groups showed no statistically significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). At the 6-month post-operation and final follow-up, VAS scores in group PRP were significantly lower than those observed in group CD, with values of 2.05 (0.74) and 1.81 (0.51) for group PRP compared to 2.57 (0.68) and 2.42 (0.72) for group B (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), respectively. This disparity was also significant when resting or sleeping at the last follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarity, there was a significant improvement in hip stiffness when, at the final follow-up, with values of 0.45 (0.67) and for group PRP compared to 0.88 (0.58) for group CD (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020), respectively. Regarding the HHS score, group PRP demonstrated a significantly higher score compared to group CD at every postoperative follow-up. The scores recorded were 82.84 (11.36) and 76.17 (9.56) at 3 months follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042), 85.88 (9.37) and 78.04 (5.14) at 6 months follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), and 87.76 (10.53) and 79.46 (7.13) at the last follow-up assessment (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). However, the Charnley score exhibited a consistent trend with HHS score only at 6 months follow-up\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn secondary outcomes, the SF-36 revealed statistically significant improvements in 6 of its 9 aspects (PF, BP, GH, SF, MH, HT) at 6 months post-operation and 5 of 9 aspects (BP, GH, SF, MH, HT) at the last follow-up. However, the Physical Component Summary (PCS) demonstrated statistically significant differences solely at the final follow-up, with values of 72.01 (11.47) compared to 64.99 (12.23) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047). In contrast, the Mental Component Summary (MCS) did not exhibit substantial difference at the last follow-up. During anxiety assessments, the S-AI and T-AI scores of group PRP were significantly superior to those of group CD at the time point of our follow-up assessment. Out of all the aforementioned scale scores, only RE in the two groups does not meet the minimum clinically important difference (MCID)\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e, which means these two groups demonstrated improvements in pain, hip function, quality of life, and psychological status. And the PRP group showed greater effectiveness in these aspects (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScore of different scales in group PRP and group CD.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperation (3m)\u003c/p\u003e \u003cp\u003e(Group PRP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperation (3m)\u003c/p\u003e \u003cp\u003e(Group CD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostoperation (6m)\u003c/p\u003e \u003cp\u003e(Group PRP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostoperation (6m)\u003c/p\u003e \u003cp\u003e(Group CD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePostoperation (Last Follow-up (Group PRP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePostoperation (Last Follow-up) (Group CD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMCID (Group PRP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eMCID\u003c/p\u003e \u003cp\u003e(Group CD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS (move)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.54 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.98 (0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.05 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.57 (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.81 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.42 (0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS (rest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.97 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.48 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.81 (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.38 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.74 (0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS (sleep)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.62 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.95 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.57 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.91 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.43 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.82 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStiffness (wake up)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.83 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.18 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.77 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.03 (1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.45 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.88 (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStiffness (rest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.67 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.06 (0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.59 (0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.55 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.96 (0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.42 (11.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76.17 (9.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e85.88 (9.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e78.04 (5.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e87.76 (10.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e79.46 (7.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharnley\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.73 (1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.89 (1.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.13 (1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.23 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.036\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.44 (1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e14.41 (1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF-36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.56 (13.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.35 (13.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e71.36 (14.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66.38 (12.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e74.57 (13.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e67.21 (12.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e6.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e7.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58.38 (22.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.28 (24.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e59.09 (23.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e56.65 (22.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e62.33 (24.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e55.28 (24.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e16.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e12.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.34 (7.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.88 (8.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e72.55 (6.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.24 (7.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e74.23 (7.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e68.84 (8.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e8.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e6.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77.53 (13.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69.72 (11.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78.32 (14.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70.83 (10.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e76.89 (13.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e68.61 (12.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e9.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e6.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.74 (5.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.21 (6.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.401\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e87.09 (6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e84.33 (8.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e86.33 (8.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e82.67 (9.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.88 (8.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.31 (10.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78.75 (9.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e73.91 (8.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e79.83 (10.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e72.31 (12.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e9.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e9.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.89 (18.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.32 (19.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e75.76 (26.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e74.12 (17.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.792\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e76.92 (22.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e73.32 (19.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e14.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e9.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80.87 (8.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.22 (8.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e84.00 (6.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77.13 (7.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e85.33 (7.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e79.26 (8.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e10.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e7.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.45 (10.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.29 (9.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47.73 (12.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e40.44 (12.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e51.28 (13.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e43.12 (12.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e5.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68.70 (15.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.56 (14.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e70.33 (14.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e65.53 (14.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e72.01 (11.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e64.99 (12.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e8.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e9.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79.10 (11.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.52 (12.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e81.40 (13.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77.37 (11.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e82.10 (13.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e76.89 (13.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e9.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e8.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.21 (1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.56 (1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00 (1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.32 (1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.78 (1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.28 (1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS-AI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.37 (3.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.51 (4.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.27 (3.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28.67 (3.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e25.88 (3.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e28.37 (4.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT-AI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.79 (2.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.12 (3.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.09 (1.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25.12 (2.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e22.78 (2.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e24.87 (3.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eONFH is a refractory disease that currently lacks effective joint-preserving procedure. Over the past 30 years, core decompression (CD) has been employed in the early stages (stages I and II) of ONFH to prevent subsequent collapse of the necrotic femoral head. However, whether it truly delay the nature course of ONFH remains a subject of long-standing debate. Recently, researchers have sought to integrate various regenerative agents with CD to enhance its efficacy. This study demonstrated limited evidence that CD combined with PRP could alter the natural course of ONFH, though it showed improved efficacy in pain relief, improved hip function and quality of life.\u003c/p\u003e \u003cp\u003eTraditional CD is performed from below the greater trochanter of the affected hip, with decompression achieved through puncture using a long needle. It not only relieves pressure within the femoral head but also removes necrotic tissue However, its ability to slow disease progression remains controversial. Hua et al. analyzed 1,379 hip joints treated solely with CD and found an overall success rate of 65%, with significant variations across different stages\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Zhu et al. analyzed 768 patients who underwent CD alone, finding a disease progression rate of 36%\u003csup\u003e52\u003c/sup\u003e. Additionally, the relatively large diameter of the Kirschner needle used may increase the risk of subtrochanteric femoral fractures post-surgery. Additionally, the use of relatively large-diameter of the Kirschner needle increase the risk of subtrochanteric femoral fractures after surgery\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Smith et al. reported that the femoral neck fracture rate during surgery and the early postoperative period was as high as 13%\u003csup\u003e54\u003c/sup\u003e. Therefore, traditional continuous drainage techniques require further refinement.\u003c/p\u003e \u003cp\u003eOne improved technique involves using small-diameter CD to reduce the fracture rate and expand the range of decompression\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Brown et al. demonstrated that small-diameter CD can improve femoral neck stability compared to single large-diameter CD procedures\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Mont et al. used 3mm diameter fine needles for decompression in 45 hips, and after a mean follow-up period of two years, 32 hips (71%) showed good to excellent HHS results\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e. However, whether it truly alters thenatural course of ONFH remains debate\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. Mohanty et al. compared the efficacy of porous small diameter CD with autologous fibula grafting, and found that the three-year survival rate for the former was significantly lower than that for the latter\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. To further enhance the femoral head survival rate in patients with, regenerative agents or cell therapies such as BMAC and BMSCshave garneredsubstantial attention. Li et al. analyzed 11 RCTS and 7 retrospective studies with a total of 1,257 hip joints, finding that stem cell therapy combined with CD was more effective in preventing collapse and radiological progression\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Piuzzi et al. reviewed the literatures to evaluate the benefits of cell-based therapy, concluding that suchcell therapies improves clinical outcomes\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e. However, due to the diversity of regenerative agents and the heterogeneity of studies necessitate further verification of their efficacy. Wang et al. performed a network meta-analysis to evaluate the efficacy of 6 different regenerative therapies for ONFH, finding that only BMAC and BMSCs delayed the disease\u0026rsquo;s natural course \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Nevertheless, the varying therapeutic efficacy, optimal injection concentration, and the effectivenessof allogeneic MSCs remains unresolved\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. Additionally, the significant trauma,, difficult preparation process, and ethical concerns associated with BMAC and BMSCs limit their clinical application. Thus, regeneration agents that are easy to prepare, readily available, and have stable therapeutic efficacy are needed. Exosomes are small vesicles secreted by cells, with diameters ranging from 40 to 160 nm, capable of transferring various bioactive molecules, including nucleic acids, proteins, and lipids, from donor to recipient cells, thereby mediating intercellular communication and molecular transpor\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e. Compared with stem cells, exosomes offer advantages such as lower immunogenicity and greater abundance, making them a therapeutic potential for ONFH\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. However, few studies have been conducted in the field of ONFH.\u003c/p\u003e \u003cp\u003eAs an easily obtainable source of growth factors, PRP has g attracted considerable attention within the medical community over the past two decades\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e. This regenerative agent contains high levels of growth factors and cytokines, which have the potential to accelerate bone repair by promoting pyhsiologic healing. It has been used as an augmentation during sugery and may serve as a useful adjuvant\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. However, after an extensive review of the literature, only 7 studies were identified that focused on the use of PRP in the treatment of ONFH\u003csup\u003e\u003cspan additionalcitationids=\"CR38 CR39 CR40 CR41 CR42\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Three of these studies were case reports or case series\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Although these studies reported the potential benefits of PRP in patients with ONFH, they were considered to provide low-quality evidence due to the limited sample size. In other 3 studies, Houdek et al. assessed the efficacy of CD in combination with PRP and BMSCs\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e, whereas D'Ambrosi et al. used synthetic bone grafts for the treatment of ONFH after administrering PRP and BMSCs after CD\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Samy reported teh use of autologous bone graft combined with PRP after CD\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Although these studies have reported some efficacy of PRP, the specific role of PRP remains unclear due to the concurrent use of bone grafts and BMSCs. Only one RCT, conducted by Aggarwal et al., directly compared the efficacy between CD plus PRP ( 25 hips) with CD alone (28 hips). The rates of survivorship from femoral head collapse and THA was 84%/68% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 92%/78% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010) in 2 groups, respectively, with a mean follow-up of 64 months, showing statistically significant results.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. The relatively small sample size of this study makes the role of PRP in the treatment of patients with early ONFH still unclear.\u003c/p\u003e \u003cp\u003eIn this study, no definitive conclusion can be drawn regarding the ability of PRP to delay the natural progression of ONFH. The reasons for this may be as follows: First, among these four collapsed hips, three were classified as 2021 ARCO type 3 or JIC type C2, with a mean LPA of 32.95\u0026deg;, indicating that the necrotic site involved weight-bearing areas, thereby presenting a high risk for collapse\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. In addition, in 3 of the 4 patients, the contralateral hip joint had already collapsed, which, according to a 2021 study, could be a contributing factor to the collapse. The study indicated that symptomatic hip collapse influences the progression of ONFH in the contralateral hip, suggesting a potential interplay between the conditions of both hips\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. This evidence suggests that these patients may be at a high risk for collapse. Second, the average age of our patients was higher than in the Aggarwal\u0026rsquo;s study, which may have contributed to the lower quality of the PRP\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. This also may be the potential reason for the differing conclusions. Lastly, compared to the Aggarwal\u0026rsquo;s study, the follow-up period of our study is relatively short and may not have been sufficient to reveal the role of PRP in ONFH. Thus, although the LPA in group A was significantly higher than that in group B at the final follow-up, we cannot definitively conclude that PRP is effective in delaying disease progression. Future randomized controlled trials with larger sample sizes and longer follow-up periods are requiredto elucidate the role of PRP in ONFH. Regarding pain, stiffness and hip function score, group A showed significantly improved outcomes at the final follow-up, including the 4 collapsed hips, all of which reached MCID, indicating that PRP have a \u0026ldquo;symptom-modifying\u0026rdquo; effect. Meanwhile, although no difference between the two MCS groups at the last follow-up, the PRP group performed significantly better than the CD group in PCS, further reflecting PRP\u0026rsquo;s role in restoring physiological function. Furthermore, in group A, 5 patients had sleep difficulties before surgery, but by the final follow-up, their sleep quality had improved. Additionally,following surgery, the patients' anxiety levels significantly decreased. The above illustrated the short term effect of this technology on symptom relief. Despite the benefits of PRP, there remain several challenges in its clinical application. PRP can be classified into leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) based on their leukocyte concentration\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e. However, the precise cellular and clinical implications of these different PRP preparations remain unclear.Moreover, the lack of data on experimental specifics or the precise composition of the PRP formulations used presents a major obstacle to interpreting the PRP studies published to date\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e. This creates challenges for the practical application of PRP in orthopedics.\u003c/p\u003e \u003cp\u003eThere are several limitations in our study. Firstly, this was a retrospective study, which may introduce some bias and lead to inaccurate findings. Secondly, the short follow-up period of this study limit the reliability of the conclusions. Large sample RCTs are needed in the future to confirm the efficacy of PRP. Thirdly, during follow-up, we found that several patients in the PRP group continued smoking and drinking post-surgery, which led to postoperative pain and poorer imaging outcomes.. Therefore, postoperative behaviors r should be standardized in future studies. Finally, the extent of necrotic borders varied throughout patients, even though only those with early ONFH were included. Individuals who have an excessively small LPA Angle, JIC type C2, or 2021ARCO type 3 are already more likely to collapse, which may have an impact on the results, and future studies need to consider the impact of this factor.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, compared to traditional CD, PRP has been shown to significantly alleviate pain, improve hip function and enhance quality of life. However, due to the limited follow-up time and relatively small sample size it remains uncertain whether this combination can enhance CD and slow the progression of ONFH. Large-scale randomized controlled trials (RCTs) are still necessary in the future to validate the effectiveness of this therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the following funding sources: The National Key Research and Development Program of China (No. 2022YFC2503100 and 2022YFC2503104), National Natural Science Foundation of China (No. 82172394) and 1.3.5 project for disciplines of excellence, West China Hospital, University (No. ZYGD23033).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee on Biomedical Research of our medical center (Approval 2024-348) and designed in accordance with the Declaration of Helsinki, which waived the need for written informed consent because patients or their legal guardians, at the time of admission, signed written consent for patients\u0026rsquo; anonymized data to be analyzed and published for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eProvenance and peer review\u003c/p\u003e\n\u003cp\u003eNot commissioned, externally peer-reviewed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization:\u0026nbsp;Haiwei Tang and Yahao Lai\u003c/p\u003e\n\u003cp\u003eInvestigation:\u0026nbsp;Haiwei Tang, Enze Zhao and Yahao Lai\u003c/p\u003e\n\u003cp\u003eMethodology: Gang Chen, Kai Zhou and Zongke Zhou\u003c/p\u003e\n\u003cp\u003eFormal analysis:\u0026nbsp;Haiwei Tang, Yahao Lai and Enze Zhao\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft:\u0026nbsp;Haiwei Tang and Yahao Lai\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Gang Chen and Zongke Zhou\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAndo W, Sakai T, Fukushima W, et al. Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head. J Orthop Sci. 2021;26(1):46\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jos.2020.06.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jos.2020.06.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWen Z, Li Y, Cai Z, et al. Global Trends and Current Status in Osteonecrosis of the Femoral Head: A Bibliometric Analysis of Publications in the Last 30 Years. Front Endocrinol (Lausanne). 2022;13:897439. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fendo.2022.897439\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2022.897439\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIkeuchi K, Hasegawa Y, Seki T, Takegami Y, Amano T, Ishiguro N. Epidemiology of nontraumatic osteonecrosis of the femoral head in Japan. Mod Rheumatol. 2015;25(2):278\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/14397595.2014.932038\u003c/span\u003e\u003cspan address=\"10.3109/14397595.2014.932038\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am. 2015;97(19):1604\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.O.00071\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.O.00071\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao DW, Yu M, Hu K, et al. Prevalence of Nontraumatic Osteonecrosis of the Femoral Head and its Associated Risk Factors in the Chinese Population: Results from a Nationally Representative Survey. Chin Med J (Engl). 2015;128(21):2843\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/0366-6999.168017\u003c/span\u003e\u003cspan address=\"10.4103/0366-6999.168017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChe Z, Song Y, Zhu L, Liu T, Li X, Huang L. Emerging roles of growth factors in osteonecrosis of the femoral head. Front Genet. 2022;13:1037190. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fgene.2022.1037190\u003c/span\u003e\u003cspan address=\"10.3389/fgene.2022.1037190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMont MA, Salem HS, Piuzzi NS, Goodman SB, Jones LC. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A 5-Year Update. J Bone Joint Surg Am. 2020;102(12):1084\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.19.01271\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.19.01271\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei QS, Li ZQ, Hong ZN, et al. Predicting Collapse in Osteonecrosis of the Femoral Head Using a New Method: Preserved Angles of Anterior and Lateral Femoral Head. J Bone Joint Surg Am. 2022;104(Suppl 2):47\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.20.00507\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.20.00507\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChughtai M, Piuzzi NS, Khlopas A, Jones LC, Goodman SB, Mont MA. An evidence-based guide to the treatment of osteonecrosis of the femoral head. Bone Joint J. 2017;99\u0026ndash;b(10):1267\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/0301-620x.99b10.Bjj-2017-0233.R2\u003c/span\u003e\u003cspan address=\"10.1302/0301-620x.99b10.Bjj-2017-0233.R2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee YJ, Cui Q, Koo KH. Is There a Role of Pharmacological Treatments in the Prevention or Treatment of Osteonecrosis of the Femoral Head? A Systematic Review. J Bone Metab. 2019;26(1):13\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11005/jbm.2019.26.1.13\u003c/span\u003e\u003cspan address=\"10.11005/jbm.2019.26.1.13\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie K, Mao Y, Qu X, et al. High-energy extracorporeal shock wave therapy for nontraumatic osteonecrosis of the femoral head. J Orthop Surg Res. 2018;13(1):25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13018-017-0705-x\u003c/span\u003e\u003cspan address=\"10.1186/s13018-017-0705-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuroda Y, Tanaka T, Miyagawa T, et al. Classification of osteonecrosis of the femoral head: Who should have surgery? Bone Joint Res. 2019;8(10):451\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/2046-3758.810.Bjr-2019-0022.R1\u003c/span\u003e\u003cspan address=\"10.1302/2046-3758.810.Bjr-2019-0022.R1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHua KC, Yang XG, Feng JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res. 2019;14(1):306. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13018-019-1359-7\u003c/span\u003e\u003cspan address=\"10.1186/s13018-019-1359-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuroda Y, Okuzu Y, Kawai T, Goto K, Matsuda S. Difference in Therapeutic Strategies for Joint-Preserving Surgery for Non-Traumatic Osteonecrosis of the Femoral Head between the United States and Japan: A Review of the Literature. Orthop Surg. 2021;13(3):742\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/os.12979\u003c/span\u003e\u003cspan address=\"10.1111/os.12979\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaushik AP, Das A, Cui Q. Osteonecrosis of the femoral head: An update in year 2012. World J Orthop. 2012;3(5):49\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5312/wjo.v3.i5.49\u003c/span\u003e\u003cspan address=\"10.5312/wjo.v3.i5.49\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong WS, Yoo JJ, Kim YM, Kim HJ. Results of multiple drilling compared with those of conventional methods of core decompression. Clin Orthop Relat Res. 2007;454:139\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.blo.0000229342.96103.73\u003c/span\u003e\u003cspan address=\"10.1097/01.blo.0000229342.96103.73\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa YC, Kim HJ, Kim SY, Kim KC, Lee YK, Koo KH. Effects of age and body mass index on the results of transtrochanteric rotational osteotomy for femoral head osteonecrosis: surgical technique. J Bone Joint Surg Am. 2011;93(Suppl 1):75\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.J.01215\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.J.01215\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarampinas P, Galanis A, Papagrigorakis E, et al. Osteonecrosis of the Femoral Head. Optimizing the Early-Stage Joint-Preserving Surgical Treatment? Maedica (Bucur). 2022;17(4):948\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.26574/maedica.2022.17.4.948\u003c/span\u003e\u003cspan address=\"10.26574/maedica.2022.17.4.948\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsawa Y, Seki T, Okura T, Takegami Y, Ishiguro N, Hasegawa Y. Long-term outcomes of curved intertrochanteric varus osteotomy combined with bone impaction grafting for non-traumatic osteonecrosis of the femoral head. Bone Joint J. 2021;103\u0026ndash;b(4):665\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/0301-620x.103b4.Bjj-2020-1107.R1\u003c/span\u003e\u003cspan address=\"10.1302/0301-620x.103b4.Bjj-2020-1107.R1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoontanapibul K, Huddleston JI 3rd, Amanatullah DF, Maloney WJ, Goodman SB. Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy. J Arthroplasty. 2021;36(6):1879\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2021.01.075\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2021.01.075\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu L, Gao F, Sun W, et al. Investigating clinical failure of core decompression with autologous bone marrow mononuclear cells grafting for the treatment of non-traumatic osteonecrosis of the femoral head. Int Orthop. 2018;42(7):1575\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00264-018-3918-7\u003c/span\u003e\u003cspan address=\"10.1007/s00264-018-3918-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;324169\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00003086-199603000-00020\u003c/span\u003e\u003cspan address=\"10.1097/00003086-199603000-00020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStulberg BN, Davis AW, Bauer TW, Levine M, Easley K. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. \u003cem\u003eClin Orthop Relat Res.\u003c/em\u003e 1991(268):140\u0026ndash;151. DOI.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohanty SP, Singh KA, Kundangar R, Shankar V. Management of non-traumatic avascular necrosis of the femoral head-a comparative analysis of the outcome of multiple small diameter drilling and core decompression with fibular grafting. Musculoskelet Surg. 2017;101(1):59\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12306-016-0431-2\u003c/span\u003e\u003cspan address=\"10.1007/s12306-016-0431-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHockett SA, Sherrill JT, Self M, Mears SC, Barnes CL, Mannen EM. Augmentation of core decompression with synthetic bone graft does not improve mechanical properties of the proximal femur. J Mech Behav Biomed Mater. 2021;115:104263. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jmbbm.2020.104263\u003c/span\u003e\u003cspan address=\"10.1016/j.jmbbm.2020.104263\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi S, Huang C, Wang W, et al. Subtrochanteric fracture after core decompression for osteonecrosis of the femoral head: a case report and literature review. BMC Musculoskelet Disord. 2024;25(1):420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12891-024-07536-5\u003c/span\u003e\u003cspan address=\"10.1186/s12891-024-07536-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan D, Wu Z, Luo S, Zou Q, Zou Z, Ye C. Impact of Femoral Neck Cortical Bone Defect Induced by Core Decompression on Postoperative Stability: A Finite Element Analysis. Biomed Res Int. 2022;2022:3667891. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2022/3667891\u003c/span\u003e\u003cspan address=\"10.1155/2022/3667891\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Xu P, Zhou L. Comparison of current treatment strategy for osteonecrosis of the femoral head from the perspective of cell therapy. Front Cell Dev Biol. 2023;11:995816. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fcell.2023.995816\u003c/span\u003e\u003cspan address=\"10.3389/fcell.2023.995816\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Hu L, Wei B, Wang J, Hou D, Deng X. Regenerative therapies for femoral head necrosis in the past two decades: a systematic review and network meta-analysis. Stem Cell Res Ther. 2024;15(1):21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13287-024-03635-1\u003c/span\u003e\u003cspan address=\"10.1186/s13287-024-03635-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z, Sun QM, Zhang FQ, Zhang QL, Wang LG, Wang WJ. Core decompression combined with autologous bone marrow stem cells versus core decompression alone for patients with osteonecrosis of the femoral head: A meta-analysis. Int J Surg. 2019;69:23\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijsu.2019.06.016\u003c/span\u003e\u003cspan address=\"10.1016/j.ijsu.2019.06.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavallo C, Boffa A, de Girolamo L, et al. Bone marrow aspirate concentrate quality is affected by age and harvest site. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2140\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-022-07153-6\u003c/span\u003e\u003cspan address=\"10.1007/s00167-022-07153-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu CA, Jildeh TR, Vopat ML, et al. Current State of Platelet-Rich Plasma and Cell-Based Therapies for the Treatment of Osteoarthritis and Tendon and Ligament Injuries. J Bone Joint Surg Am. 2022;104(15):1406\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.21.01112\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.21.01112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesouza C, Dubey R, Shetty V. Platelet-rich plasma in chronic Achilles tendinopathy. Eur J Orthop Surg Traumatol. 2023;33(8):3255\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00590-023-03570-6\u003c/span\u003e\u003cspan address=\"10.1007/s00590-023-03570-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodeo SA, Orthobiologics. Current Status in 2023 and Future Outlook. J Am Acad Orthop Surg. 2023;31(12):604\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5435/jaaos-d-22-00808\u003c/span\u003e\u003cspan address=\"10.5435/jaaos-d-22-00808\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomoyasu A, Higashio K, Kanomata K, et al. Platelet-rich plasma stimulates osteoblastic differentiation in the presence of BMPs. Biochem Biophys Res Commun. 2007;361(1):62\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bbrc.2007.06.142\u003c/span\u003e\u003cspan address=\"10.1016/j.bbrc.2007.06.142\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNoh KC, Liu XN, Zhuan Z, et al. Leukocyte-Poor Platelet-Rich Plasma-Derived Growth Factors Enhance Human Fibroblast Proliferation In Vitro. Clin Orthop Surg. 2018;10(2):240\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4055/cios.2018.10.2.240\u003c/span\u003e\u003cspan address=\"10.4055/cios.2018.10.2.240\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Ambrosi R, Biancardi E, Massari G, Ragone V, Facchini RM. Survival Analysis after Core Decompression in Association with Platelet-Rich Plasma, Mesenchymal Stem Cells, and Synthetic Bone Graft in Patients with Osteonecrosis of the Femoral Head. Joints. 2018;6(1):16\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0038-1626740\u003c/span\u003e\u003cspan address=\"10.1055/s-0038-1626740\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuadilla J, Fiz N, Andia I, S\u0026aacute;nchez M. Arthroscopic management and platelet-rich plasma therapy for avascular necrosis of the hip. Knee Surg Sports Traumatol Arthrosc. 2012;20(2):393\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-011-1587-9\u003c/span\u003e\u003cspan address=\"10.1007/s00167-011-1587-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoudek MT, Wyles CC, Collins MS, et al. Stem Cells Combined With Platelet-rich Plasma Effectively Treat Corticosteroid-induced Osteonecrosis of the Hip: A Prospective Study. Clin Orthop Relat Res. 2018;476(2):388\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11999.0000000000000033\u003c/span\u003e\u003cspan address=\"10.1007/s11999.0000000000000033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbrahim V, Dowling H. Platelet-rich plasma as a nonsurgical treatment option for osteonecrosis. Pm r. 2012;4(12):1015\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.pmrj.2012.07.009\u003c/span\u003e\u003cspan address=\"10.1016/j.pmrj.2012.07.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePak J, Lee JH, Jeon JH, Lee SH. Complete resolution of avascular necrosis of the human femoral head treated with adipose tissue-derived stem cells and platelet-rich plasma. J Int Med Res. 2014;42(6):1353\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0300060514546940\u003c/span\u003e\u003cspan address=\"10.1177/0300060514546940\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamy AM. Management of osteonecrosis of the femoral head: A novel technique. Indian J Orthop. 2016;50(4):359\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/0019-5413.185590\u003c/span\u003e\u003cspan address=\"10.4103/0019-5413.185590\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAggarwal AK, Poornalingam K, Jain A, Prakash M. Combining Platelet-Rich Plasma Instillation With Core Decompression Improves Functional Outcome and Delays Progression in Early-Stage Avascular Necrosis of Femoral Head: a 4.5- to 6-Year Prospective Randomized Comparative Study. J Arthroplasty. 2021;36(1):54\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2020.07.010\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2020.07.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown PJ, Mannava S, Seyler TM et al. Multiple Small Diameter Drillings Increase Femoral Neck Stability Compared with Single Large Diameter Femoral Head Core Decompression Technique for Avascular Necrosis of the Femoral Head. \u003cem\u003eSurg Technol Int.\u003c/em\u003e 2016;29:247\u0026ndash;254. DOI.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCilla M, Checa S, Preininger B, et al. Femoral head necrosis: A finite element analysis of common and novel surgical techniques. Clin Biomech (Bristol Avon). 2017;48:49\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clinbiomech.2017.07.005\u003c/span\u003e\u003cspan address=\"10.1016/j.clinbiomech.2017.07.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan Y, He H, Wan Z, et al. Study on the outcome of patients with aseptic femoral head necrosis treated with percutaneous multiple small-diameter drilling core decompression: a retrospective cohort study based on magnetic resonance imaging and equivalent sphere model analysis. J Orthop Surg Res. 2020;15(1):264. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13018-020-01786-4\u003c/span\u003e\u003cspan address=\"10.1186/s13018-020-01786-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoo KH, Mont MA, Cui Q, et al. The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study. J Arthroplasty. 2022;37(6):1074\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2022.02.009\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2022.02.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGausden EB, Qudsi R, Boone MD, OʼGara B, Ruzbarsky JJ, Lorich DG. Tranexamic Acid in Orthopaedic Trauma Surgery: A Meta-Analysis. J Orthop Trauma. 2017;31(10):513\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/bot.0000000000000913\u003c/span\u003e\u003cspan address=\"10.1097/bot.0000000000000913\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharnley J. Charnley JJLfaotht, practice. Numerical grading of clinical results. 1979:20\u0026ndash;24. DOI.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41(5):582\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.Mlr.0000062554.74615.4c\u003c/span\u003e\u003cspan address=\"10.1097/01.Mlr.0000062554.74615.4c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeo MGH, Goh GS, Chen JY, Lo NN, Yeo SJ, Liow MHL. Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty? J Arthroplasty. 2020;35(9):2458\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2020.04.034\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2020.04.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu S, Zhang X, Chen X, Wang Y, Li S, Qian W. Comparison of cell therapy and other novel adjunctive therapies combined with core decompression for the treatment of osteonecrosis of the femoral head: a systematic review and meta-analysis of 20 studies. Bone Joint Res. 2021;10(7):445\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/2046-3758.107.Bjr-2020-0418.R1\u003c/span\u003e\u003cspan address=\"10.1302/2046-3758.107.Bjr-2020-0418.R1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYue J, Guo X, Wang R, et al. Preliminary report of the outcomes and indications of single approach, double-channel core decompression with structural bone support and bone grafting for osteonecrosis of the femoral head. BMC Musculoskelet Disord. 2022;23(1):198. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12891-022-05149-4\u003c/span\u003e\u003cspan address=\"10.1186/s12891-022-05149-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith SW, Fehring TK, Griffin WL, Beaver WB. Core decompression of the osteonecrotic femoral head. J Bone Joint Surg Am. 1995;77(5):674\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/00004623-199505000-00003\u003c/span\u003e\u003cspan address=\"10.2106/00004623-199505000-00003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res. 2004;429131\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.blo.0000150128.57777.8e\u003c/span\u003e\u003cspan address=\"10.1097/01.blo.0000150128.57777.8e\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoon BH, Lee YK, Kim KC, Ha YC, Koo KH. No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis. Int Orthop. 2018;42(12):2737\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00264-018-3977-9\u003c/span\u003e\u003cspan address=\"10.1007/s00264-018-3977-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadile F, Bernasconi A, Russo S, Maffulli N. Core decompression versus other joint preserving treatments for osteonecrosis of the femoral head: a meta-analysis. Br Med Bull. 2016;118(1):33\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bmb/ldw010\u003c/span\u003e\u003cspan address=\"10.1093/bmb/ldw010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi M, Chen D, Ma Y, Zheng M, Zheng Q. Stem cell therapy combined with core decompression versus core decompression alone in the treatment of avascular necrosis of the femoral head: a systematic review and meta-analysis. J Orthop Surg Res. 2023;18(1):560. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13018-023-04025-8\u003c/span\u003e\u003cspan address=\"10.1186/s13018-023-04025-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiuzzi NS, Chahla J, Schrock JB, et al. Evidence for the Use of Cell-Based Therapy for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature. J Arthroplasty. 2017;32(5):1698\u0026ndash;708. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2016.12.049\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2016.12.049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman SB, Maruyama M, Inflammation. Bone Healing and Osteonecrosis: From Bedside to Bench. J Inflamm Res. 2020;13:913\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/jir.S281941\u003c/span\u003e\u003cspan address=\"10.2147/jir.S281941\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalluri R, LeBleu VS. The biology, function, and biomedical applications of exosomes. Science. 2020;367(6478). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1126/science.aau6977\u003c/span\u003e\u003cspan address=\"10.1126/science.aau6977\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXia L, Zhang C, Lv N, et al. AdMSC-derived exosomes alleviate acute lung injury via transferring mitochondrial component to improve homeostasis of alveolar macrophages. Theranostics. 2022;12(6):2928\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7150/thno.69533\u003c/span\u003e\u003cspan address=\"10.7150/thno.69533\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDos Santos RG, Santos GS, Alkass N, et al. The regenerative mechanisms of platelet-rich plasma: A review. Cytokine. 2021;144:155560. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cyto.2021.155560\u003c/span\u003e\u003cspan address=\"10.1016/j.cyto.2021.155560\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFice MP, Miller JC, Christian R, et al. The Role of Platelet-Rich Plasma in Cartilage Pathology: An Updated Systematic Review of the Basic Science Evidence. Arthroscopy. 2019;35(3):961\u0026ndash;e976963. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arthro.2018.10.125\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2018.10.125\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuiz-Moneo P, Molano-Mu\u0026ntilde;oz J, Prieto E, Algorta J. Plasma rich in growth factors in arthroscopic rotator cuff repair: a randomized, double-blind, controlled clinical trial. Arthroscopy. 2013;29(1):2\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arthro.2012.08.014\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2012.08.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsawa Y, Seki T, Takegami Y, Makida K, Ochiai S, Imagama S. Collapse Progression or Cessation Affects the Natural History of Contralateral Osteonecrosis of the Femoral Head. J Arthroplasty. 2021;36(12):3839\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2021.08.005\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2021.08.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe ADK, Enweze L, DeBaun MR, Dragoo JL. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med. 2018;11(4):624\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12178-018-9527-7\u003c/span\u003e\u003cspan address=\"10.1007/s12178-018-9527-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChahla J, Cinque ME, Piuzzi NS, et al. A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature. J Bone Joint Surg Am. 2017;99(20):1769\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.16.01374\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.16.01374\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Osteonecrosis of the femoral head, small-diameter drilling core decompression, Platelet-rich plasma","lastPublishedDoi":"10.21203/rs.3.rs-5339366/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5339366/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOsteonecrosis of the femoral head (ONFH) is a challenging condition, primarily affecting young and middle-aged individuals, which results in hip dysfunction and, ultimately, femoral head collapse. However, the comparative effectiveness of joint-preserving procedures, particularly in the early stages of ONFH, remains inconclusive. This study aims to evaluate the efficacy of a novel technique called small-diameter core decompression (CD) combined with platelet-rich plasma (PRP), for the treatment of early-stage ONFH.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eClinical data of 40 patients (51 hips) with pre-collapse stage ONFH were retrospectively analyzed. Nineteen patients (23 hips) underwent small-diameter CD (group A) and 21 patients (28 hips) received conventional CD (group B) and follow-up was conducted every 3 months. Hip radiographs (X-rays and MRI) were evaluated using various ONFH staging systems (Preserved Angles, ARCO, JIC, and CHFJ stages). X-rays were performed at each follow-up to assess femoral head collapse and the rate of total hip arthroplasty (THA). Additionally, the Visual Analogue Scale (VAS), Harris Hip Score (HHS), Charnley score, SF-36, Athens Insomnia Scale (AIS), and State-Trait Anxiety Inventory (STAI) were used to evaluate hip pain, function, quality of life, and psychological status. These assessments were conducted both preoperatively and at each follow-up visit.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean follow-up duration in Group CD\u0026thinsp;+\u0026thinsp;PRP was 11.57 months, with a femoral head survivorship of 82.61%. One hip underwent THA 14 months after the novel procedure. In Group CD, with an average follow-up period of 11.32 months, femoral head survivorship was 60.71% (p\u0026thinsp;=\u0026thinsp;0.111), and 2 hips required THA (p\u0026thinsp;=\u0026thinsp;0.999). At the final follow-up, the VAS, stiffness, HHS and Charnley scores of the PRP group showed significant improvements compared to those of the CD group. Quality of life, anxiety and insomnia were also significantly improved in the PRP group compared to CD group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe application of PRP following CD results in significant pain relief, improved short-term functional outcomes, and enhanced quality of life compared to CD alone. However, whether it hinders disease progression in early ONFH and reduces the conversion rate to THA and femoral head collapse remains uncertain. Further research with larger sample sizes and extended follow-up is needed to validate these preliminary findings.\u003c/p\u003e","manuscriptTitle":"Efficacy of Small-Diameter Core Decompression with Platelet-Rich Plasma in Early Osteonecrosis of the Femoral Head: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-06 11:06:32","doi":"10.21203/rs.3.rs-5339366/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-29T11:27:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-28T06:57:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-28T06:57:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-10-27T01:54:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5e194e5d-31d2-4337-97fd-30aa2b287654","owner":[],"postedDate":"November 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T15:59:32+00:00","versionOfRecord":{"articleIdentity":"rs-5339366","link":"https://doi.org/10.1186/s12891-024-08243-x","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-01-03 15:57:06","publishedOnDateReadable":"January 3rd, 2025"},"versionCreatedAt":"2024-11-06 11:06:32","video":"","vorDoi":"10.1186/s12891-024-08243-x","vorDoiUrl":"https://doi.org/10.1186/s12891-024-08243-x","workflowStages":[]},"version":"v1","identity":"rs-5339366","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5339366","identity":"rs-5339366","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}