Osteonecrosis of the Femoral Head: treatment before the collapse. Experience with decompression and biological therapy

Osteonecrosis of the Femoral Head: treatment before the collapse. 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Experience with decompression and biological therapy Yuri Lara-Taranchenko, Iñaki Mimendia, Víctor Barro Ojeda, María Guzmám, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5129432/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted 11 You are reading this latest preprint version Abstract INTRODUCTION Osteonecrosis is a disabling condition and one of the most frequent causes of hip arthroplasty in the young population. Early detection and treatment in stages prior to femoral head collapse are essential to prevent progression and conversion to total hip arthroplasty (THA). The present study aims to demonstrate the results obtained in the treatment of patients with initial stages of ONFH, treated with a decompression system that associates biologic therapy (platelet-rich plasma and mesenchymal stem cells) (PERFUSE). METHODOLOGY: Retrospective unicentric study in which all patients with ONFH treated with decompression of the necrotic area and biological therapy between May 2018 and May 2023, were collected. Demographic data of the patients (age and gender), risk factors for AVN, area of necrosis (Kerboul), ARCO classification, collapse rate and conversion to THA were obtained. RESULTS 24 patients with ONFH were treated using the PERFUSE system. The mean age was 47.67 years old, and the mean follow-up was 26.1 months. The mean improvement in the modified Harris Hip Score (mHHS) was 10.11 (from 70.79 to 80.56; p = 0.018). Patients who developed femoral head collapse had worse mHHS scores. 6 patients (25%) progressed to femoral head collapse, of which 2 (8.33%) were converted to total hip arthroplasty (THA). The probability of collapse-free survival at 12 months was 90.9% (SD 6.2; 95%CI, 79.5–100%), and at 18 months it was 85.2% (SD 8.0; 95%CI, 70.9–100%), and at 24 months it was 65.7% (SD 11.7; 95%CI, 46.3–93.2%). CONCLUSION Core decompression with bone aspirate marrow and platelet-rich plasma can enhances bone regeneration and delays femoral head collapse, especially when implemented in early-stage ONFH. In this sense, combining both, core decompression with biological support can offer a promising approach for managing early-stage ONFH. Despite encouraging outcomes, further research is needed to optimize treatment protocols and evaluate long-term efficacy. Osteonecrosis of the femoral head decompression biological therapy collapse total hip arthroplasty Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Osteonecrosis of the femoral head (ONFH) is the most prevalent form of osteonecrosis, caused by an impaired blood supply to the proximal femur, resulting in bone cell death, fracture, and collapse of the articular surface ( 1 ). According to UK registries, the incidence of osteonecrosis ranges from 1.4-3 per 100.000 individuals, with the hip being the most frequently affected site, accounting for 75.9% of cases ( 2 ). This condition predominantly affects individuals between their third and fifth decades of life and maybe bilateral in 40–70% of cases ( 3 , 4 ). The exact pathomechanism of ONFH remains poorly understood. It is influenced by various factors, including underlying medical conditions and medications that lead to vascular obstruction, alterations in osteocyte function, and genetic predisposition ( 5 , 6 ). ONFH is characterised by compromised subchondral microcirculation, resulting in bone necrosis, microfractures, and eventual subchondral collapse ( 1 ). This process is closely associated with the compartmental structure of bone, where elevated intraosseous pressure (exceeding 30 mmHg) obstructs venous outflow and nutrient arteries; thereby disrupting microvascular circulation and causing ischemia ( 8 ). Alterations in intravascular blood supply can arise from both traumatic or non-traumatic causes, such as corticosteroid therapy, alcohol abuse, drug intake, chemotherapy, and hypercoagulable conditions. ONFH accounts for 5 to 18% of total hip arthroplasties and is the third leading indication for total hip arthroplasty (THA) in patients under 50 ( 2 ). Therefore, early diagnosis is critical given the significant impact on younger and middle-aged populations, and the 70–80% progression rate in untreated cases ( 9 ). Prompt evaluation of young and active patients who exhibit risk factors and the onset of hip pain should be performed expeditiously, as subchondral collapse typically appears 8 months after the onset of hip pain ( 9 ). Currently available diagnostic modalities include hip radiographs, computer-assisted tomography (CT), magnetic resonance imaging (MRI), and radionuclide examinations ( 8 ). Among these methods, MRI is considered the most accurate benchmark, as it remains the gold standard for identifying precollapse lesions and determining their extent and location. MRI has a diagnostic accuracy of approximately 99%, depicting the infarcted area as a smooth, well-circumscribed hypodense line on T1-weighted images ( Figure N. 1 ) ( 8 ). Upon diagnosing ONFH, it becomes critical to distinguish between precollapse and postcollapse lesions to ensure optimal treatment outcomes. Various classification systems have been proposed to enhance understanding and guide the selection of appropriate therapeutic strategies. Their primary goal is to identify precollapse lesions, suitable for joint-preserving procedures, as opposed to postcollapse lesions, better treated with THA ( 7 , 8 ). Among the most widely used classifications are the Ficat, Arlet, and Steinberg classifications, alongside the Association Research Circulation Osseous (ARCO) system. Despite its popularity, the Ficat classification is limited by its inability to quantify lesion size, thus hindering disease progression or staging assessment ( 8 ). In contrast, ARCO classification integrates radiographic, MRI, and histologic findings, thereby addressing Ficat’s limitations by incorporating parameters for lesion location and size, providing valuable insights into the diagnosis, treatment approach and prognosis of ONFH ( 10 ). Precollapse lesions, classified as ARCO stages I-II, are amenable to joint-preserving procedures, such as femoral osteotomies, non-vascularized or vascularized bone grafting, and core decompression techniques. Core decompression (CD) involves creating tunnels within the necrotic area to reduce intraosseous pressure, thereby enhancing local blood flow and neovascularization ( 4 ). This procedure is analogous to decompression surgeries performed in nerve or compartment syndromes as it interrupts the cycle of medullary hypertension in osteonecrosis. Immediate pain relief follows a cortical breach, accompanied by improved venous drainage and promotion of femoral head revascularization through complex physiological responses ( 11 ). CD has demonstrated superior outcomes in the management of precollapse, small, and medially located lesions ( 12 ). It is hypothesized that patients with FHAN lack sufficient progenitor cells with osteogenic repair capacity, essential for bone remodelling in osteonecrotic regions ( 7 ). This deficit may explain the incomplete repair and healing observed in some cases of CD. Therefore, treatment strategies should include adjunctive biological therapies as part of a comprehensive approach ( 13 ). Autologous bone marrow transplantation was first proposed as a treatment for osteonecrosis in 1990, yielding promising outcomes in subsequent studies ( 14 , 15 ). The therapeutic efficacy of bone marrow cells may be attributed to the increased presence of osteogenic stem cells, delivered to the femoral head via marrow implantation. Additionally, injected marrow stromal cells are believed to secrete angiogenic cytokines, thereby promoting angiogenesis and enhancing osteogenesis, which further contributes to the success of bone marrow implantation ( 15 ). Besides, platelet-rich plasma (PRP) can also be used to increase the healing process by creating a microenvironment conducive to stem cell proliferation and differentiation, thus accelerating bone repair ( 16 ). Although CD with biological augmentation is frequently cited as a preferred technique for managing osteonecrosis of the femoral head, its ability to prevent joint collapse and prolong the survival of THA remains a subject of ongoing debate. This study aims to evaluate the clinical and radiological outcomes of CD combined with autologous stem cells and platelet-rich plasma (PRP) using the PerFuse™ system in a cohort of patients with ONFH. METHODS Study Design Following IRB approval, this study was conducted as a longitudinal cohort study. The institutional database was retrospectively reviewed to identify all patients with ONFH who underwent CD combined with autologous stem cells (PerFuse™ system). Settings/Inclusion criteria Patients who underwent core decompression combined with autologous stem cells (PerFuse™ system) at a high-volume Hip Surgery Unit between May 2018 and September 2023, were analyzed. Inclusion criteria were limited to patients with a confirmed diagnosis of osteonecrosis of the femoral head and minimum follow-up of 12 months . All diagnoses and treatments were conducted by specialized hip surgeons. Standard Diagnostic Protocol/Routine Diagnostic Evaluation In the Hip Unit Outpatient Care, each patient with hip pain underwent a thorough diagnostic evaluation, beginning with an evaluation of risk factors, including smoking, corticosteroid use, previous hip trauma, alcohol and drug intake, chemotherapy, and hypercoagulable states. A physical examination followed, focused on gait and intraarticular signs, such as pain elicited by the FADIR, FABER, and Fitzgerald maneuvers. Diagnostic imaging included posteroanterior pelvis, axial hip radiographs, and MRI, with the latter confirming the diagnosis ( Figure N.1 ). Upon confirmation of the diagnosis, patients were classified according to the ARCO system, which categorizes them into two groups: precollapse lesions (I-II-IIIA) and collapse lesions (IIIB-IV). Patients in precollapse phase were offered to be treated using the PerFuse™ system, consisting of decompression of the necrotic area (through a 6mm cannula), followed by local infiltration of stem cells derived from bone marrow and peripheral blood ( Figure N.2 ). Surgical procedure Biologic preparation Platelet-rich plasma and stem cells are obtained by collecting a venous blood sample and a bone marrow aspiration, respectively. The patient is positioned supine on the orthopaedic table. Under sterile conditions, a 1 cm skin incision is made at the anterior superior iliac spine, and bone marrow is aspirated using a prefabricated cannula ( Figure N.2 ). A total of 160-180cc of whole blood and bone marrow aspirate should be obtained and mixed. The mixture is then placed into tubes and centrifuged for 15 minutes to isolate the final stem cell preparation, which is subsequently injected through the cannula. Core decompression During the core decompression procedure, the patient remains supine on an orthopaedic table with fluoroscopy. The mayor trochanter and instrument orientation are marked. A one cm skin incision is made on the lateral aspect of the proximal femur, just distal to the major trochanter, with the entry point positioned proximal to the level of the lesser trochanter. Once the entry point is identified, a trocar is advanced from lateral to medial and parallel to the femoral neck under fluoroscopic guidance to reach the necrotic area. Upon reaching, the trocar is withdrawn while maintaining the cannula in place, through which the biologic mixture is infiltrated ( Figure N.2 ). Postoperative protocol Early mobilization: All patients were encouraged to sit up and begin progressive weight-bearing walking within 24 hours of surgery. Partial weight bearing: Partial weight bearing, defined as placing no more than 50% of body weight on the operated leg, was allowed from the first day after surgery. Patients used crutches or a walker to assist with ambulation. Full weight bearing: Full weight bearing, defined as placing full body weight on the operated leg, was gradually reintroduced over 4-6 weeks. The specific timeline for full weight bearing was determined based on the location and size of the preoperative necrotic area. T hromboembolic prophylaxis: Low molecular weight heparin was administered for 10 days postoperatively. Data collection Anonymized clinical records provided data, including demographics (sex, age, comorbidities) and risk factors (alcohol, smoke, corticoid treatment, haematological disease, viral infections, rheumatic disease). Surgical time and postsurgical data such as hospital stay and weight-bearing tolerance were also recorded. The modified Harris Hip Score (mHHS), complication, collapse and arthroplasty conversion rates were obtained. Statistical analysis Descriptive statistics were used for prevalence and demographic data. The data were subjected to a normality test using the Shapiro–Wilk test. Subsequently, parametric and non-parametric tests were used for the analyses. Continuous variables were analysed using the Student T-test, the Wilcoxon T-test and the Mann–Whitney test. The statistical significance was defined as a two-tailed probability of less than 0.05. Variables were reported as mean and standard deviation or median and interquartile range depending on data distribution. Kaplan-Meier survival analysis was conducted with the 95% confidence limits indicated on the survival curves. Statistical analysis was performed using open-source software JASP, JASP Team (2024). JASP (Version 0.19) [Computer software]. RESULTS Patients and Descriptive Data In our database review, 24 patients treated with PerFuse™ system were identified ( Table N. 1 ). Of these, 19 patients (79.2%) were men, and 5 were women (20.8%). The mean age was 47.67 years old (SD 9.3 years). Bilateral hip involvement was observed in 18 cases (75%). The mean affected area, according to the Kerboul angle, was 223.2º (SD 90.2). The mean follow-up was 26.1 months (SD 15.2 months) ( Table N.1 ). Risk factors for AVN The most frequent risk factors identified were treatment corticosteroid therapy (7 patients, 29.17%), alcohol intake (8 patients, 33.3%), and smoking (9 patients, 37.5%). Other less common risk factors included a history of trauma, leukaemia or lymphoma, prior radiotherapy, sickle cell disease, organ transplantation, viral infections, and rheumatic disease ( Table N.1 ). Surgical and postsurgical data The mean surgical time was 63.4 minutes (SD 25.9 minutes). Partial weight-bearing was allowed in 4.94 weeks (SD 2 weeks), and total weight-bearing in 7 weeks (SD 2.3 weeks). Modified Harris Hip Score. The mean postoperative total mHHS at the end of follow-up was 80.5 (SD 15.7). When analyzing, the pain and function of the mHHS, the mean postoperative pain score was 38.3 (SD 8.4), and the mean postoperative function score was 42.2 (SD 9.12) ( Table N.2 ) ( Figure N.4 ). Both the overall postoperative mHHS and postoperative pain scores improved statistically significantly (p < 0.005). There were statistical differences between total HHS between patients with precollapse lesions vs postcollapse lesions ( Table N.3 ). Conversion to THA, collapse, and complications. During the follow-up, a collapse of the necrotic area was observed in 6 patients (25%) ( Figure N.3 ), of which 2 (8.3%) were converted to THA ( Table N.4 ). No relationship was found between ARCO severity, the necrotic area (medial, central, lateral) nor the Kerboul angle, and the collapse rate. No major complications were detected, but one case (4.17%) developed persistent pain in the greater trochanter corresponding with the entry point system. The results of the Kaplan-Meier survival analyses are shown in Figure N.5 . With a median follow-up of 23 months (minimum 3 and maximum 55 months), the probability of collapse-free survival at 12 months was 90.9% (SD 6.2; 95%CI, 79.5–100%), and at 18 months it was 85.2% (SD 8.0; 95%CI, 70.9–100%), and at 24 months it was 65.7% (SD 11.7; 95%CI, 46.3–93.2%). DISCUSSION The present study provides valuable insights into the management of osteonecrosis of the femoral head using a novel approach that combines core decompression with bone marrow aspirate and platelet-rich plasma (PRP) via PerFuse™ system. Our findings indicate that the probability of collapse-free survival at 24 months was 65.7%, with most collapses occurring between 12 and 24 months. Notably, only 6 patients experienced femoral head collapse following the preserving treatment, and of these, only 2 required conversion to THA. Additionally, our data revealed significant improvements in functional and pain outcomes, as measured by mHHS, particularly when comparing presurgical and postsurgical precollapse cases. These results suggest that integrating CD with autologous biologic augmentation may offer a promising strategy for delaying or preventing femoral head collapse, enhancing patient function and reducing pain in early-stage ONFH. Our previous therapeutic strategy involved decompression through debridement of the necrotic focus, followed by the implantation of autologous bone marrow concentrate and tricalcium phosphate to provide structural support. However, the 5-year follow-up data revealed a concerningly low median survival rate to femoral head collapse, falling below 80% ( 17 ). Although an improvement in HHS was observed, the overall efficacy of this strategy in preventing collapse was limited. In response to these challenges, we shifted to our current strategy, which utilized the PerFuse™ system. We continue to employ autologous bone marrow concentrate based on previous evidence demonstrating superior outcomes in patients with ONFH. The key technical advantages of our approach include replacing the broach with an 8mm cannula and performing curettage. In our cohort, a 6mm cannula was used, facilitating straightforward backfilling while maintaining a size suitable for immediate post-surgery weight-bearing. Nonetheless, in real practice, the reported average time to partial and full weight-bearing was 5 weeks and 7 weeks, respectively. This system also avoids the thermal effects of reamers, which can generate heat and potentially compromise clinical outcomes. THA remains the most widespread treatment for end-stage ONFH ( 18 ), but it is unsuitable for younger or early-stage patients due to potential reduced hip mobility and complications. Core decompression (CD) is the leading preservation method for early-stage ONFH (ARCO I-II). Over time, the reported success rate of CD has fluctuated, and its overall efficacy remains controversial. Success rates range from 48–80% in patients treated solely with CD, compared to 74–82% in those receiving CD combined with biological therapies such as autologous bone marrow aspirate, cultured mesenchymal stem cells and platelet-rich plasma ( 11 ). According to a recent metanalysis, the combination of CD with biological therapies demonstrated superior outcomes in terms of pain relief, reduction of the necrotic area, clinical improvement, and delayed femoral head collapse ( 19 ). Bearing this in mind, regenerative approaches, such as the use of PRP, are being explored to augment the effects of core decompression ( 16 ). When marrow stem cells are combined with PRP to treat ONFH, the growth factors present in the PRP enhance the differentiation of mesenchymal stem cells into osteoblasts, and chondrocytes. PRP exerts its effects through three mechanisms by modulating the interactions of multiple growth factors and cytokines along various signalling pathways: stimulating angiogenesis and osteogenesis to accelerate bone repair, suppressing inflammatory responses within necrotic lesions, and preventing glucocorticoid-induced apoptosis ( 20 ). Despite, promising early results, challenges include identifying optimal cell source, standardizing cell processing, refining transplantation techniques, and determining the required number of cells. Long-term efficacy data on transplanted stem cells are limited and debated, highlighting the need for further research on preparation protocols and stem cell ratios for optimal therapeutic outcomes. The outcomes observed in our study population are consistent with those reported in the literature. The mean age of patients was 47 years, and several risk factors were identified, including corticosteroid therapy, alcohol abuse, smoking, radiotherapy, trauma and sickle cell disease. A total of 85% of cases treated with CD with biological support (PerFuse™ system) demonstrated no radiological progression, a result that aligns with the reported rates in the literature, which ranges from 77–94% ( 19 ). A progression rate of 38% has been documented in cases Ficat I-II treated with PerFuse™ system. In contrast, the progression rate in our study was lower, at 25%. Six patients (5 male and 1 female) experienced femoral head collapse, with a mean time to collapse of 18 months. Of these, only 2 required conversion to THA. All cases of progression occurred in patients with more advanced ONFH (ARCO stage 2), which may explain the failure of the joint-preserving treatment. Based on our previous findings, the femoral head free-collapse survival rate was 33% at 15 months using the previously described approach, with 9 out of 15 patients requiring conversion to THA. In the current study, the overall free-collapse survival rate is reported as 90.1% at 12 months, 85.2% at 18 months, and 65.7% at 24 months. This marked improvement in preventing femoral head collapse can be attributed to the synergistic effect of stem cell therapy combined with PRP, which fosters a favorable biological environment for early-stage ONFH. Regarding clinical outcomes, as measured by mHHS, we observed not only prolonged time to conversion of THA or collapse, but also significant improvements in both pain levels and total HHS scores among our patients. We posit that clinical outcomes, particularly those that affect pain and functional status, are ultimately more significant than radiological findings, as these parameters have a direct impact on patient quality of life. Corroborating our findings, a meta-analysis of 14 studies, including 540 patients, comparing CD alone vs. CD with bone marrow stem cell implantation demonstrated a statistically significant increase in HHS at 12 and 24 months postoperatively. Furthermore, the analysis revealed a significant reduction in postoperative pain at 6, 12, and 24 months ( 15 ). The strengths of our study included that the intervention was performed at the same hospital by the same unit, and the results were measured by the same observer. However, several limitations were encountered in this study. Primarily, the sample size was relatively modest, largely attributable to the low frequency of detecting ONFH in ARCO stages I and II, where joint preserving procedures are primarily applied. Potential limitations include the absence of a control group and the retrospective design of the study. CONCLUSION Our results suggest that core decompression with bone aspirate marrow and platelet-rich plasma can enhances bone regeneration and delays femoral head collapse, especially when implemented in early-stage ONFH. In this sense, combining both, core decompression with biological support can offer a promising approach for managing early-stage ONFH. Despite encouraging outcomes, further research is needed to optimize treatment protocols and evaluate long-term efficacy. Declarations Conflicts of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. Funding The authors didn’t receive any financial support. Author Contribution I.M, V.B, D.S, D.C, E.G, A.H ejectuded the surgeries. Y.L, M.G, M.H, A.A collected the data, did the statistical analysis and wrote the manuscript.All the authors reviewed and corrected the manuscript. 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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 Sep;69:23–31. Han J, Gao F, Li Y, Ma J, Sun W, Shi L, et al. The Use of Platelet-Rich Plasma for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review. BioMed Res Int. 2020 Mar 7;2020:1–11. Tables Table 1. Demographic variables and risk factors. Number of cases 24 cases Mean age (SD) 47.67 (9.29) Gender Male (%) 19 (79.17) Female (%) 5 (20.83) BMI (SD) 26.19 (3.76) ASA score (%) I 3 (15.79) II 11 (57.90) III 5 (26.32) Bilateral (%) 18 (75.00) Mean follow-up in months (SD) 24.00 (13.16) Risk factors Steroids (%) 7 (29.17) Alcohol (%) 8 (33.33) Smoker (%) 9 (37.50) Leukemia (%) Radiotherapy (%) Sickle cell disease (%) Trauma history (%) 0 (0.00) 2 (8.33) 2 (8.33) 2 (8.33) BMI: Body Mass Index. SD: standard deviation. Table 2. Postsurgical and presurgical Harris Hip Score. Preoperative and postoperative HHS Preoperative Postoperative Change p-value 1 Pain (SD) 30.21 (9.07) 38.33 (8.43) 8.11 (10.09) 0.007 Function (SD) 40.58 (5.78) 42.22 (9.12) 2.00 (10.85) 0.120 Total (SD) 70.79 (13.67) 80.56 (15.68) 10.11 (19.88) 0.018 1 Wilcoxon test. p <0.05 Table 3. Modified Harris Hip Score differences between non-collapse and collapse patients. Non-collapse patients Collapse patients p-value mHHS pain difference 11.14 (6.12) -2.50 (14.91) 0.033 1 mHHS function difference 4.21 (8.29) -5.75 (16.32) 0.240 2 mHHS total difference 15.36 (13.28) -8.25 (29.86) 0.024 2 1 Independent samples Student test . 2 Independent samples Mann-Whitney test. p <0.05 Subtractions were obtained for HHS differences. HHS differences= Postoperative HHS – Preoperative HHS. Table 4. Details of patients with collapse. N. Age Gender BMI Risk factor Classification THA Time to collapse (months) Time to THA (months) Mean time to collapse (SD) Mean time to THR 1 43 Male 27.46 Alcohol Smoker ARCO 2B Steinberg 2 Kerboul 211º No 14 - 17.83 (6.89) 27.5 (0.71) 2 53 Female 21.11 Alcohol Smoker Radiotherapy ARCO 2C Steinberg 2 Kerboul 344º Yes 23 28 3 50 Male 28.41 Alcohol Smoker ARCO 2A Steinberg 2 Kerboul 154º Yes 24 27 4 50 Male 25.45 None ARCO 2C Steinberg 2 No 23 - 5 44 Male 24.36 None ARCO 2B Steinberg 2 No 9 - 6 50 Male 28.80 Alcohol ARCO 2C Steinberg 2 No 11 - BMI: Body Mass Index. THA=Total Hip Arthroplasty. ARCO: A lateral, B central, C lateral. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted Editorial decision: Revision requested 25 Nov, 2024 Reviews received at journal 19 Nov, 2024 Reviews received at journal 11 Nov, 2024 Reviews received at journal 11 Nov, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviewers agreed at journal 08 Nov, 2024 Reviewers agreed at journal 07 Nov, 2024 Reviewers invited by journal 05 Nov, 2024 Editor assigned by journal 24 Sep, 2024 Submission checks completed at journal 24 Sep, 2024 First submitted to journal 21 Sep, 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. 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Lara-Taranchenko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYJCCAwwFQJK9/eADIMXDR5wWA5DaM8lgio04e0BqJRLMJEBsgloMbuQ+BNpil88/IyGt8muOnQwbA/PDRzfwakk3AGpJtpxx5uGx27LbkoEOYzM2zsGrJQ3kF2YDhuMJabcltzEDtfCwSROhpd5A/kCCWbHktnqitRw2MDiRYMb4cdthwlokzzxjOJBgcNzA8MyZZGnGbcd52JgJ+IXveBrzhw8V1QZyx9sPfvy5rdqen7354WN8WhQOAIkEKIeZB0ziUQ4C8g1IHMYfBFSPglEwCkbByAQA189H5K/OysEAAAAASUVORK5CYII=","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":true,"prefix":"","firstName":"Yuri","middleName":"","lastName":"Lara-Taranchenko","suffix":""},{"id":382607372,"identity":"474d5421-d343-4d48-b429-c48e0bd7a70c","order_by":1,"name":"Iñaki Mimendia","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Iñaki","middleName":"","lastName":"Mimendia","suffix":""},{"id":382607373,"identity":"e0494ca5-a680-449b-95ce-8e85b559d159","order_by":2,"name":"Víctor Barro Ojeda","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Víctor","middleName":"Barro","lastName":"Ojeda","suffix":""},{"id":382607374,"identity":"8152a241-3882-4c22-a498-6513c0169a88","order_by":3,"name":"María Guzmám","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"","lastName":"Guzmám","suffix":""},{"id":382607375,"identity":"b3379ab5-7b4d-47ea-908f-7db0ede3b2de","order_by":4,"name":"Margalida Hernández","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Margalida","middleName":"","lastName":"Hernández","suffix":""},{"id":382607376,"identity":"447fb83e-f8bc-4f44-a338-ef442eb51b5a","order_by":5,"name":"Andrés Aliaga Martínez","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Andrés","middleName":"Aliaga","lastName":"Martínez","suffix":""},{"id":382607377,"identity":"14ea2225-b613-4a4e-a20a-55160d3ad9cd","order_by":6,"name":"Diego Soza","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Soza","suffix":""},{"id":382607378,"identity":"6493767b-4252-4dbb-8408-b1510492f274","order_by":7,"name":"Diego Collado","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Collado","suffix":""},{"id":382607379,"identity":"4212b48a-fcf3-418d-ae0b-58903a4ecce8","order_by":8,"name":"Ernesto Guerra Farfán","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Ernesto","middleName":"Guerra","lastName":"Farfán","suffix":""},{"id":382607380,"identity":"e5a7f5e0-abd9-45c2-8e99-151111cbab88","order_by":9,"name":"Alejandro Hernández","email":"","orcid":"","institution":"Hospital Universitario Vall d'Hebron","correspondingAuthor":false,"prefix":"","firstName":"Alejandro","middleName":"","lastName":"Hernández","suffix":""}],"badges":[],"createdAt":"2024-09-21 15:55:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5129432/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5129432/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00590-025-04257-w","type":"published","date":"2025-04-03T15:57:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70948352,"identity":"64160a63-62fd-4f81-b0f6-c833b44a956a","added_by":"auto","created_at":"2024-12-09 13:19:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1897637,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiological images of Osteonecrosis of the Femoral Head.\u003c/strong\u003e 50 years-old patient with ARCO 2C ONFH and a Kerboul extension area of 168º.\u003c/p\u003e","description":"","filename":"DefinitiveimagesONFH1.png","url":"https://assets-eu.researchsquare.com/files/rs-5129432/v1/f9a4da27108a4581bc84e680.png"},{"id":70947697,"identity":"269e4d4a-d407-4bed-9085-9db3775f2d85","added_by":"auto","created_at":"2024-12-09 13:11:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4461284,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurgical procedure. \u003c/strong\u003ePeripheral blood sample and Bone marrow aspiration are obtained and centrifuged. Decompression of the necrotic area is done through an impaction cannula guided with an intraoperative fluoroscope. Once the necrotic area is achieved, the centrifuged solution is injected through the cannula.\u003c/p\u003e","description":"","filename":"DefinitiveimagesONFH2.png","url":"https://assets-eu.researchsquare.com/files/rs-5129432/v1/da39586e0c91752a2a48ffdf.png"},{"id":70947699,"identity":"74662f8a-e637-4600-b572-c252055a5ee5","added_by":"auto","created_at":"2024-12-09 13:11:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2743240,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCollapse of the femoral head. \u003c/strong\u003eLose of the femoral sphericity in a\u003cstrong\u003e \u003c/strong\u003e50 years old man with ONFH ARCO 2B. Time to collapse 23m.\u003c/p\u003e","description":"","filename":"DefinitiveimagesONFH3.png","url":"https://assets-eu.researchsquare.com/files/rs-5129432/v1/1a0f827a9de611c9c2cf5e96.png"},{"id":70948353,"identity":"e8a24cdd-e9ae-4bae-a56b-4ee798adbbb2","added_by":"auto","created_at":"2024-12-09 13:19:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":151073,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDifferences between preoperative and postoperative Harris Hip Score.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"DefinitiveimagesONFH4.png","url":"https://assets-eu.researchsquare.com/files/rs-5129432/v1/87223d04c8cc2051381712f7.png"},{"id":70947696,"identity":"0b0304b2-a450-4d92-ba5f-f8d9a0cfa0bb","added_by":"auto","created_at":"2024-12-09 13:11:31","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":261278,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival to femoral head collapse. \u003c/strong\u003eKaplan-Meier plot for collapse-free survival for avascular femoral head necrosis treated with decompression and biological therapy (shaded area shows 95% CI).\u003c/p\u003e","description":"","filename":"DefinitiveimagesONFH5.png","url":"https://assets-eu.researchsquare.com/files/rs-5129432/v1/6b561701badf65094f664ffb.png"},{"id":80081979,"identity":"6e4bb2a6-7532-42a4-ac28-211ae51a3511","added_by":"auto","created_at":"2025-04-07 16:04:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":18433812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5129432/v1/b457e00d-25d6-404f-8d1e-2b446b41e283.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Osteonecrosis of the Femoral Head: treatment before the collapse. Experience with decompression and biological therapy","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOsteonecrosis of the femoral head (ONFH) is the most prevalent form of osteonecrosis, caused by an impaired blood supply to the proximal femur, resulting in bone cell death, fracture, and collapse of the articular surface (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). According to UK registries, the incidence of osteonecrosis ranges from 1.4-3 per 100.000 individuals, with the hip being the most frequently affected site, accounting for 75.9% of cases (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This condition predominantly affects individuals between their third and fifth decades of life and maybe bilateral in 40\u0026ndash;70% of cases (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe exact pathomechanism of ONFH remains poorly understood. It is influenced by various factors, including underlying medical conditions and medications that lead to vascular obstruction, alterations in osteocyte function, and genetic predisposition (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). ONFH is characterised by compromised subchondral microcirculation, resulting in bone necrosis, microfractures, and eventual subchondral collapse (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This process is closely associated with the compartmental structure of bone, where elevated intraosseous pressure (exceeding 30 mmHg) obstructs venous outflow and nutrient arteries; thereby disrupting microvascular circulation and causing ischemia (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Alterations in intravascular blood supply can arise from both traumatic or non-traumatic causes, such as corticosteroid therapy, alcohol abuse, drug intake, chemotherapy, and hypercoagulable conditions.\u003c/p\u003e \u003cp\u003eONFH accounts for 5 to 18% of total hip arthroplasties and is the third leading indication for total hip arthroplasty (THA) in patients under 50 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, early diagnosis is critical given the significant impact on younger and middle-aged populations, and the 70\u0026ndash;80% progression rate in untreated cases (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Prompt evaluation of young and active patients who exhibit risk factors and the onset of hip pain should be performed expeditiously, as subchondral collapse typically appears 8 months after the onset of hip pain (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Currently available diagnostic modalities include hip radiographs, computer-assisted tomography (CT), magnetic resonance imaging (MRI), and radionuclide examinations (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Among these methods, MRI is considered the most accurate benchmark, as it remains the gold standard for identifying precollapse lesions and determining their extent and location. MRI has a diagnostic accuracy of approximately 99%, depicting the infarcted area as a smooth, well-circumscribed hypodense line on T1-weighted images (\u003cb\u003eFigure N. 1\u003c/b\u003e) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUpon diagnosing ONFH, it becomes critical to distinguish between precollapse and postcollapse lesions to ensure optimal treatment outcomes. Various classification systems have been proposed to enhance understanding and guide the selection of appropriate therapeutic strategies. Their primary goal is to identify precollapse lesions, suitable for joint-preserving procedures, as opposed to postcollapse lesions, better treated with THA (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Among the most widely used classifications are the Ficat, Arlet, and Steinberg classifications, alongside the Association Research Circulation Osseous (ARCO) system. Despite its popularity, the Ficat classification is limited by its inability to quantify lesion size, thus hindering disease progression or staging assessment (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In contrast, ARCO classification integrates radiographic, MRI, and histologic findings, thereby addressing Ficat\u0026rsquo;s limitations by incorporating parameters for lesion location and size, providing valuable insights into the diagnosis, treatment approach and prognosis of ONFH (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrecollapse lesions, classified as ARCO stages I-II, are amenable to joint-preserving procedures, such as femoral osteotomies, non-vascularized or vascularized bone grafting, and core decompression techniques. Core decompression (CD) involves creating tunnels within the necrotic area to reduce intraosseous pressure, thereby enhancing local blood flow and neovascularization (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This procedure is analogous to decompression surgeries performed in nerve or compartment syndromes as it interrupts the cycle of medullary hypertension in osteonecrosis. Immediate pain relief follows a cortical breach, accompanied by improved venous drainage and promotion of femoral head revascularization through complex physiological responses (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCD has demonstrated superior outcomes in the management of precollapse, small, and medially located lesions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). It is hypothesized that patients with FHAN lack sufficient progenitor cells with osteogenic repair capacity, essential for bone remodelling in osteonecrotic regions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This deficit may explain the incomplete repair and healing observed in some cases of CD. Therefore, treatment strategies should include adjunctive biological therapies as part of a comprehensive approach (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAutologous bone marrow transplantation was first proposed as a treatment for osteonecrosis in 1990, yielding promising outcomes in subsequent studies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The therapeutic efficacy of bone marrow cells may be attributed to the increased presence of osteogenic stem cells, delivered to the femoral head via marrow implantation. Additionally, injected marrow stromal cells are believed to secrete angiogenic cytokines, thereby promoting angiogenesis and enhancing osteogenesis, which further contributes to the success of bone marrow implantation (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Besides, platelet-rich plasma (PRP) can also be used to increase the healing process by creating a microenvironment conducive to stem cell proliferation and differentiation, thus accelerating bone repair (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough CD with biological augmentation is frequently cited as a preferred technique for managing osteonecrosis of the femoral head, its ability to prevent joint collapse and prolong the survival of THA remains a subject of ongoing debate. This study aims to evaluate the clinical and radiological outcomes of CD combined with autologous stem cells and platelet-rich plasma (PRP) using the PerFuse\u0026trade; system in a cohort of patients with ONFH.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing IRB approval, this study was conducted as a longitudinal cohort study. The institutional database was retrospectively reviewed to identify all patients with ONFH who underwent CD combined with autologous stem cells (PerFuse™ system).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSettings/Inclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who underwent\u0026nbsp;core decompression combined with autologous stem cells (PerFuse™ system) at a high-volume Hip Surgery Unit between May 2018 and September 2023, were analyzed. Inclusion criteria were limited to patients with a confirmed diagnosis of osteonecrosis of the femoral head and \u003cem\u003eminimum follow-up of 12 months\u003c/em\u003e. All diagnoses and treatments were conducted by specialized hip surgeons.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStandard Diagnostic Protocol/Routine Diagnostic Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the Hip Unit Outpatient Care, each patient with hip pain underwent a thorough diagnostic evaluation, beginning with an evaluation of risk factors, including smoking, corticosteroid use, previous hip trauma, alcohol and drug intake, chemotherapy, and hypercoagulable states. A physical examination followed, focused on gait and intraarticular signs, such as pain elicited by the FADIR, FABER, and Fitzgerald maneuvers. Diagnostic imaging included posteroanterior pelvis, axial hip radiographs, and MRI, with the latter confirming the diagnosis (\u003cstrong\u003eFigure N.1\u003c/strong\u003e). Upon confirmation of the diagnosis, patients were classified according to the ARCO system, which categorizes them into two groups: precollapse lesions (I-II-IIIA) and collapse lesions (IIIB-IV). Patients in precollapse phase were offered to be treated using the\u0026nbsp;PerFuse™ system, consisting of decompression of the necrotic area (through a 6mm cannula), followed by local infiltration of stem cells derived from bone marrow and peripheral blood (\u003cstrong\u003eFigure N.2\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eBiologic preparation\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePlatelet-rich plasma and stem cells are obtained by collecting a venous blood sample and a bone marrow aspiration, respectively. The patient is positioned supine on the orthopaedic table. Under sterile conditions, a 1 cm skin incision is made at the anterior superior iliac spine, and bone marrow is aspirated using a prefabricated cannula (\u003cstrong\u003eFigure N.2\u003c/strong\u003e). A total of 160-180cc of whole blood and bone marrow aspirate should be obtained and mixed. The mixture is then placed into tubes and centrifuged for 15 minutes to isolate the final stem cell preparation, which is subsequently injected through the cannula.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCore decompression\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDuring the core decompression procedure, the patient remains supine on an orthopaedic table with fluoroscopy. The mayor trochanter and instrument orientation are marked. A one cm skin incision is made on the lateral aspect of the proximal femur, just distal to the major trochanter, with the entry point positioned proximal to the level of the lesser trochanter. Once the entry point is identified, a trocar is advanced from lateral to medial and parallel to the femoral neck under fluoroscopic guidance to reach the necrotic area. Upon reaching, the trocar is withdrawn while maintaining the cannula in place, through which the biologic mixture is infiltrated (\u003cstrong\u003eFigure N.2\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePostoperative protocol\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEarly mobilization:\u003c/em\u003e\u003c/strong\u003e All patients were encouraged to sit up and begin progressive weight-bearing walking within 24 hours of surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePartial weight bearing:\u003c/em\u003e\u003c/strong\u003e Partial weight bearing, defined as placing no more than 50% of body weight on the operated leg, was allowed from the first day after surgery. Patients used crutches or a walker to assist with ambulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFull weight bearing:\u003c/em\u003e\u003c/strong\u003e Full weight bearing, defined as placing full body weight on the operated leg, was gradually reintroduced over 4-6 weeks. The specific timeline for full weight bearing was determined based on the location and size of the preoperative necrotic area.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eT\u003cstrong\u003ehromboembolic prophylaxis:\u003c/strong\u003e\u003c/em\u003e Low molecular weight heparin was administered for 10 days postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnonymized clinical records provided data, including demographics (sex, age, comorbidities) and risk factors (alcohol, smoke, corticoid treatment, haematological disease, viral infections, rheumatic disease). Surgical time and postsurgical data such as hospital stay and weight-bearing tolerance were also recorded. The modified Harris Hip Score (mHHS), complication, collapse and arthroplasty conversion rates were obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used for prevalence and demographic data. The data were subjected to a normality test using the Shapiro–Wilk test. Subsequently, parametric and non-parametric tests were used for the analyses. Continuous variables were analysed using the Student T-test, the Wilcoxon T-test and the Mann–Whitney test. The statistical significance was defined as a two-tailed probability of less than 0.05. Variables were reported as mean and standard deviation or median and interquartile range depending on data distribution. Kaplan-Meier survival analysis was conducted with the 95% confidence limits indicated on the survival curves. Statistical analysis was performed using open-source software JASP, JASP Team (2024). JASP (Version 0.19) [Computer software].\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePatients and Descriptive Data\u003c/h2\u003e \u003cp\u003eIn our database review, 24 patients treated with PerFuse\u0026trade; system were identified (\u003cb\u003eTable N. 1\u003c/b\u003e). Of these, 19 patients (79.2%) were men, and 5 were women (20.8%). The mean age was 47.67 years old (SD 9.3 years). Bilateral hip involvement was observed in 18 cases (75%). The mean affected area, according to the Kerboul angle, was 223.2\u0026ordm; (SD 90.2). The mean follow-up was 26.1 months (SD 15.2 months) (\u003cb\u003eTable N.1\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors for AVN\u003c/h2\u003e \u003cp\u003eThe most frequent risk factors identified were treatment corticosteroid therapy (7 patients, 29.17%), alcohol intake (8 patients, 33.3%), and smoking (9 patients, 37.5%). Other less common risk factors included a history of trauma, leukaemia or lymphoma, prior radiotherapy, sickle cell disease, organ transplantation, viral infections, and rheumatic disease (\u003cb\u003eTable N.1\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSurgical and postsurgical data\u003c/h2\u003e \u003cp\u003eThe mean surgical time was 63.4 minutes (SD 25.9 minutes). Partial weight-bearing was allowed in 4.94 weeks (SD 2 weeks), and total weight-bearing in 7 weeks (SD 2.3 weeks).\u003c/p\u003e \u003cp\u003e \u003cb\u003eModified Harris Hip Score.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean postoperative total mHHS at the end of follow-up was 80.5 (SD 15.7). When analyzing, the pain and function of the mHHS, the mean postoperative pain score was 38.3 (SD 8.4), and the mean postoperative function score was 42.2 (SD 9.12) (\u003cb\u003eTable N.2\u003c/b\u003e) (\u003cb\u003eFigure N.4\u003c/b\u003e). Both the overall postoperative mHHS and postoperative pain scores \u003cem\u003eimproved statistically significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005).\u003c/em\u003e There were statistical differences between total HHS between patients with precollapse lesions vs postcollapse lesions (\u003cb\u003eTable N.3\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConversion to THA, collapse, and complications.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDuring the follow-up, a collapse of the necrotic area was observed in 6 patients (25%) (\u003cb\u003eFigure N.3\u003c/b\u003e), of which 2 (8.3%) were converted to THA (\u003cb\u003eTable N.4\u003c/b\u003e). No relationship was found between ARCO severity, the necrotic area (medial, central, lateral) nor the Kerboul angle, and the collapse rate. No major complications were detected, but one case (4.17%) developed persistent pain in the greater trochanter corresponding with the entry point system. The results of the Kaplan-Meier survival analyses are shown in \u003cb\u003eFigure N.5\u003c/b\u003e. With a median follow-up of 23 months (minimum 3 and maximum 55 months), the probability of collapse-free survival at 12 months was 90.9% (SD 6.2; 95%CI, 79.5\u0026ndash;100%), and at 18 months it was 85.2% (SD 8.0; 95%CI, 70.9\u0026ndash;100%), and at 24 months it was 65.7% (SD 11.7; 95%CI, 46.3\u0026ndash;93.2%).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study provides valuable insights into the management of osteonecrosis of the femoral head using a novel approach that combines core decompression with bone marrow aspirate and platelet-rich plasma (PRP) via PerFuse\u0026trade; system. Our findings indicate that the probability of collapse-free survival at 24 months was 65.7%, with most collapses occurring between 12 and 24 months. Notably, only 6 patients experienced femoral head collapse following the preserving treatment, and of these, only 2 required conversion to THA. Additionally, our data revealed significant improvements in functional and pain outcomes, as measured by mHHS, particularly when comparing presurgical and postsurgical precollapse cases. These results suggest that integrating CD with autologous biologic augmentation may offer a promising strategy for delaying or preventing femoral head collapse, enhancing patient function and reducing pain in early-stage ONFH.\u003c/p\u003e \u003cp\u003eOur previous therapeutic strategy involved decompression through debridement of the necrotic focus, followed by the implantation of autologous bone marrow concentrate and tricalcium phosphate to provide structural support. However, the 5-year follow-up data revealed a concerningly low median survival rate to femoral head collapse, falling below 80% (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Although an improvement in HHS was observed, the overall efficacy of this strategy in preventing collapse was limited. In response to these challenges, we shifted to our current strategy, which utilized the PerFuse\u0026trade; system. We continue to employ autologous bone marrow concentrate based on previous evidence demonstrating superior outcomes in patients with ONFH. The key technical advantages of our approach include replacing the broach with an 8mm cannula and performing curettage. In our cohort, a 6mm cannula was used, facilitating straightforward backfilling while maintaining a size suitable for immediate post-surgery weight-bearing. Nonetheless, in real practice, the reported average time to partial and full weight-bearing was 5 weeks and 7 weeks, respectively. This system also avoids the thermal effects of reamers, which can generate heat and potentially compromise clinical outcomes.\u003c/p\u003e \u003cp\u003eTHA remains the most widespread treatment for end-stage ONFH (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), but it is unsuitable for younger or early-stage patients due to potential reduced hip mobility and complications. Core decompression (CD) is the leading preservation method for early-stage ONFH (ARCO I-II). Over time, the reported success rate of CD has fluctuated, and its overall efficacy remains controversial. Success rates range from 48\u0026ndash;80% in patients treated solely with CD, compared to 74\u0026ndash;82% in those receiving CD combined with biological therapies such as autologous bone marrow aspirate, cultured mesenchymal stem cells and platelet-rich plasma (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to a recent metanalysis, the combination of CD with biological therapies demonstrated superior outcomes in terms of pain relief, reduction of the necrotic area, clinical improvement, and delayed femoral head collapse (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBearing this in mind, regenerative approaches, such as the use of PRP, are being explored to augment the effects of core decompression (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). When marrow stem cells are combined with PRP to treat ONFH, the growth factors present in the PRP enhance the differentiation of mesenchymal stem cells into osteoblasts, and chondrocytes. PRP exerts its effects through three mechanisms by modulating the interactions of multiple growth factors and cytokines along various signalling pathways: stimulating angiogenesis and osteogenesis to accelerate bone repair, suppressing inflammatory responses within necrotic lesions, and preventing glucocorticoid-induced apoptosis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite, promising early results, challenges include identifying optimal cell source, standardizing cell processing, refining transplantation techniques, and determining the required number of cells. Long-term efficacy data on transplanted stem cells are limited and debated, highlighting the need for further research on preparation protocols and stem cell ratios for optimal therapeutic outcomes.\u003c/p\u003e \u003cp\u003eThe outcomes observed in our study population are consistent with those reported in the literature. The mean age of patients was 47 years, and several risk factors were identified, including corticosteroid therapy, alcohol abuse, smoking, radiotherapy, trauma and sickle cell disease. A total of 85% of cases treated with CD with biological support (PerFuse\u0026trade; system) demonstrated no radiological progression, a result that aligns with the reported rates in the literature, which ranges from 77\u0026ndash;94% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A progression rate of 38% has been documented in cases Ficat I-II treated with PerFuse\u0026trade; system. In contrast, the progression rate in our study was lower, at 25%. Six patients (5 male and 1 female) experienced femoral head collapse, with a mean time to collapse of 18 months. Of these, only 2 required conversion to THA. All cases of progression occurred in patients with more advanced ONFH (ARCO stage 2), which may explain the failure of the joint-preserving treatment.\u003c/p\u003e \u003cp\u003eBased on our previous findings, the femoral head free-collapse survival rate was 33% at 15 months using the previously described approach, with 9 out of 15 patients requiring conversion to THA. In the current study, the overall free-collapse survival rate is reported as 90.1% at 12 months, 85.2% at 18 months, and 65.7% at 24 months. This marked improvement in preventing femoral head collapse can be attributed to the synergistic effect of stem cell therapy combined with PRP, which fosters a favorable biological environment for early-stage ONFH.\u003c/p\u003e \u003cp\u003eRegarding clinical outcomes, as measured by mHHS, we observed not only prolonged time to conversion of THA or collapse, but also significant improvements in both pain levels and total HHS scores among our patients. We posit that clinical outcomes, particularly those that affect pain and functional status, are ultimately more significant than radiological findings, as these parameters have a direct impact on patient quality of life. Corroborating our findings, a meta-analysis of 14 studies, including 540 patients, comparing CD alone vs. CD with bone marrow stem cell implantation demonstrated a statistically significant increase in HHS at 12 and 24 months postoperatively. Furthermore, the analysis revealed a significant reduction in postoperative pain at 6, 12, and 24 months (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe strengths of our study included that the intervention was performed at the same hospital by the same unit, and the results were measured by the same observer. However, several limitations were encountered in this study. Primarily, the sample size was relatively modest, largely attributable to the low frequency of detecting ONFH in ARCO stages I and II, where joint preserving procedures are primarily applied. Potential limitations include the absence of a control group and the retrospective design of the study.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur results suggest that core decompression with bone aspirate marrow and platelet-rich plasma can enhances bone regeneration and delays femoral head collapse, especially when implemented in early-stage ONFH. In this sense, combining both, core decompression with biological support can offer a promising approach for managing early-stage ONFH. Despite encouraging outcomes, further research is needed to optimize treatment protocols and evaluate long-term efficacy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors didn\u0026rsquo;t receive any financial support.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eI.M, V.B, D.S, D.C, E.G, A.H ejectuded the surgeries. Y.L, M.G, M.H, A.A collected the data, did the statistical analysis and wrote the manuscript.All the authors reviewed and corrected the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKonarski W, Poboży T, Śliwczyński A, Kotela I, Krakowiak J, Hordowicz M, et al. Avascular Necrosis of Femoral Head\u0026mdash;Overview and Current State of the Art. Int J Environ Res Public Health. 2022 Jun 15;19(12):7348. \u003c/li\u003e\n\u003cli\u003eCooper C, Steinbuch M, Stevenson R, Miday R, Watts NB. The epidemiology of osteonecrosis: findings from the GPRD and THIN databases in the UK. Osteoporos Int. 2010 Apr;21(4):569\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eCarli A, Albers A, S\u0026eacute;guin C, Harvey EJ. The Medical and Surgical Treatment of ARCO Stage-I and II Osteonecrosis of the Femoral Head: A Critical Analysis Review. JBJS Rev [Internet]. 2014 Feb 11 [cited 2024 Aug 26];2(2). Available from: https://journals.lww.com/01874474-201402000-00002\u003c/li\u003e\n\u003cli\u003eAtilla B, Bakırcıoğlu S, Shope AJ, Parvizi J. Joint-preserving procedures for osteonecrosis of the femoral head. EFORT Open Rev. 2019 Dec;4(12):647\u0026ndash;58. \u003c/li\u003e\n\u003cli\u003eGeorge G, Lane JM. Osteonecrosis of the Femoral Head. JAAOS Glob Res Rev [Internet]. 2022 May [cited 2024 Aug 26];6(5). Available from: https://journals.lww.com/10.5435/JAAOSGlobal-D-21-00176\u003c/li\u003e\n\u003cli\u003eLiu YF, Chen WM, Lin YF, Yang RC, Lin MW, Li LH, et al. Type II Collagen Gene Variants and Inherited Osteonecrosis of the Femoral Head. N Engl J Med. 2005 Jun 2;352(22):2294\u0026ndash;301. \u003c/li\u003e\n\u003cli\u003eMoya-Angeler J. Current concepts on osteonecrosis of the femoral head. World J Orthop. 2015;6(8):590. \u003c/li\u003e\n\u003cli\u003ePetek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT Open Rev. 2019 Mar;4(3):85\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eMin BW, Song KS, Cho CH, Lee SM, Lee KJ. Untreated Asymptomatic Hips in Patients With Osteonecrosis of the Femoral Head. Clin Orthop. 2008 May;466(5):1087\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eYue J, Guo X, Wang R, Li B, Sun Q, Liu W, et al. Reliability and repeatability of 2021 ARCO classification and its guiding significance in treatment of nontraumatic osteonecrosis of the femoral head. BMC Musculoskelet Disord. 2023 Jun 8;24(1):469. \u003c/li\u003e\n\u003cli\u003eHua K chi, Yang X gang, Feng J tao, Wang F, Yang L, Zhang H, 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. 2019 Dec;14(1):306. \u003c/li\u003e\n\u003cli\u003eKarimi M, Moharrami A, Vahedian Ardakani M, Mirghaderi SP, Ghadimi E, Mortazavi SJ. Predictors of Core Decompression Success in Patients with Femoral Head Avascular Necrosis. Arch Bone Jt Surg [Internet]. 2023 May [cited 2024 Aug 31];(Online First). Available from: https://doi.org/10.22038/abjs.2022.61327.3011\u003c/li\u003e\n\u003cli\u003eHernigou P, Trousselier M, Roubineau F, Bouthors C, Chevallier N, Rouard H, et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg. 2016;8(1):1. \u003c/li\u003e\n\u003cli\u003eHernigou P, Poignard A, Manicom O, Mathieu G, Rouard H. The use of percutaneous autologous bone marrow transplantation in nonunion and avascular necrosis of bone. J Bone Joint Surg Br. 2005 Jul;87(7):896\u0026ndash;902. \u003c/li\u003e\n\u003cli\u003eXu S, Zhang L, Jin H, Shan L, Zhou L, Xiao L, et al. Autologous Stem Cells Combined Core Decompression for Treatment of Avascular Necrosis of the Femoral Head: A Systematic Meta-Analysis. BioMed Res Int. 2017;2017:6136205. \u003c/li\u003e\n\u003cli\u003eRamaswamy Reddy S, Reddy R, Babu Nc, Ashok G. Stem-cell therapy and platelet-rich plasma in regenerative medicines: A review on pros and cons of the technologies. J Oral Maxillofac Pathol. 2018;22(3):367. \u003c/li\u003e\n\u003cli\u003eHernandez A, Nu\u0026ntilde;ez JH, Sallent A, Gargallo-Margarit A, Gallardo-Calero I, Barro V. Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip. Clin Orthop Surg. 2020;12(2):151. \u003c/li\u003e\n\u003cli\u003eZhao D, Cui D, Wang B, Tian F, Guo L, Yang L, et al. Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells. Bone. 2012 Jan;50(1):325\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eWang Z, Sun Q meng, Zhang F qiang, Zhang Q li, Wang L guo, Wang W ji. 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 Sep;69:23\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eHan J, Gao F, Li Y, Ma J, Sun W, Shi L, et al. The Use of Platelet-Rich Plasma for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review. BioMed Res Int. 2020 Mar 7;2020:1\u0026ndash;11. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic variables and risk factors.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"493\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e24 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;47.67 (9.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eMale (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e19 (79.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eFemale (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e5 (20.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e26.19 (3.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA score (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e3 (15.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e11 (57.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e5 (26.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBilateral (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e18 (75.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 326px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean follow-up in months (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e24.00 (13.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eSteroids (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e7 (29.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eAlcohol (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e8 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eSmoker (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e9 (37.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eLeukemia (%)\u003c/p\u003e\n \u003cp\u003eRadiotherapy (%)\u003c/p\u003e\n \u003cp\u003eSickle cell disease (%)\u003c/p\u003e\n \u003cp\u003eTrauma history (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003cp\u003e2 (8.33)\u003c/p\u003e\n \u003cp\u003e2 (8.33)\u003c/p\u003e\n \u003cp\u003e2 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eBMI: Body Mass Index. SD: standard deviation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003ePostsurgical and presurgical Harris Hip Score.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"566\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 566px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative and postoperative HHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003csup\u003e\u0026nbsp;1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e30.21 (9.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e38.33 (8.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e8.11 (10.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunction (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e40.58 (5.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e42.22 (9.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2.00 (10.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e70.79 (13.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e80.56 (15.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e10.11 (19.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Wilcoxon test. \u003cem\u003ep \u0026lt;0.05\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eModified Harris Hip Score differences between non-collapse and collapse patients.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"453\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-collapse patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCollapse patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emHHS pain difference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e11.14 (6.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.50 (14.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.033 \u003csup\u003e\u0026nbsp;1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emHHS function difference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e4.21 (8.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-5.75 (16.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.240 \u003cstrong\u003e\u003csup\u003e\u0026nbsp;2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emHHS total difference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e15.36 (13.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-8.25 (29.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.024\u003c/strong\u003e \u003cstrong\u003e\u003csup\u003e\u0026nbsp;2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e\u0026nbsp; Independent samples Student test . \u0026nbsp;\u003csup\u003e2\u003c/sup\u003e Independent samples Mann-Whitney test. \u003cem\u003ep \u0026lt;0.05\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSubtractions were obtained for HHS differences. HHS differences= Postoperative HHS \u0026ndash; Preoperative HHS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Details of patients with collapse.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"716\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClassification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTHA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to collapse (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to THA (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean time to collapse (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean time to THR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e27.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eARCO 2B\u003c/p\u003e\n \u003cp\u003eSteinberg 2\u003c/p\u003e\n \u003cp\u003eKerboul 211\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e17.83 (6.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e27.5 (0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e21.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eARCO 2C\u003c/p\u003e\n \u003cp\u003eSteinberg 2\u003c/p\u003e\n \u003cp\u003eKerboul 344\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e28.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eARCO 2A\u003c/p\u003e\n \u003cp\u003eSteinberg 2\u003c/p\u003e\n \u003cp\u003eKerboul 154\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e25.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eARCO 2C\u003c/p\u003e\n \u003cp\u003eSteinberg 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e24.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eARCO 2B\u003c/p\u003e\n \u003cp\u003eSteinberg 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e28.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eARCO 2C\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSteinberg 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eBMI: Body Mass Index. THA=Total Hip Arthroplasty. ARCO: A lateral, B central, C lateral.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Osteonecrosis of the femoral head, decompression, biological therapy, collapse, total hip arthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-5129432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5129432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eINTRODUCTION\u003c/h2\u003e \u003cp\u003eOsteonecrosis is a disabling condition and one of the most frequent causes of hip arthroplasty in the young population. Early detection and treatment in stages prior to femoral head collapse are essential to prevent progression and conversion to total hip arthroplasty (THA). The present study aims to demonstrate the results obtained in the treatment of patients with initial stages of ONFH, treated with a decompression system that associates biologic therapy (platelet-rich plasma and mesenchymal stem cells) (PERFUSE).\u003c/p\u003e\u003ch2\u003eMETHODOLOGY:\u003c/h2\u003e \u003cp\u003eRetrospective unicentric study in which all patients with ONFH treated with decompression of the necrotic area and biological therapy between May 2018 and May 2023, were collected. Demographic data of the patients (age and gender), risk factors for AVN, area of necrosis (Kerboul), ARCO classification, collapse rate and conversion to THA were obtained.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003e24 patients with ONFH were treated using the PERFUSE system. The mean age was 47.67 years old, and the mean follow-up was 26.1 months. The mean improvement in the modified Harris Hip Score (mHHS) was 10.11 (from 70.79 to 80.56; p\u0026thinsp;=\u0026thinsp;0.018). Patients who developed femoral head collapse had worse mHHS scores. 6 patients (25%) progressed to femoral head collapse, of which 2 (8.33%) were converted to total hip arthroplasty (THA). The probability of collapse-free survival at 12 months was 90.9% (SD 6.2; 95%CI, 79.5\u0026ndash;100%), and at 18 months it was 85.2% (SD 8.0; 95%CI, 70.9\u0026ndash;100%), and at 24 months it was 65.7% (SD 11.7; 95%CI, 46.3\u0026ndash;93.2%).\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eCore decompression with bone aspirate marrow and platelet-rich plasma can enhances bone regeneration and delays femoral head collapse, especially when implemented in early-stage ONFH. In this sense, combining both, core decompression with biological support can offer a promising approach for managing early-stage ONFH. Despite encouraging outcomes, further research is needed to optimize treatment protocols and evaluate long-term efficacy.\u003c/p\u003e","manuscriptTitle":"Osteonecrosis of the Femoral Head: treatment before the collapse. Experience with decompression and biological therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 13:11:26","doi":"10.21203/rs.3.rs-5129432/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-26T02:15:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-19T11:38:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T15:08:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T15:07:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175067244528702566505795403617492095926","date":"2024-11-11T14:43:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309858302536851700309950774764946739739","date":"2024-11-08T16:01:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277999865264757392962809733897200928304","date":"2024-11-07T19:12:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-06T00:42:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-24T11:50:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-24T11:48:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Orthopaedic Surgery \u0026 Traumatology","date":"2024-09-21T15:54:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"134ae9ac-4d0a-4255-a815-388774cbd976","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T15:59:05+00:00","versionOfRecord":{"articleIdentity":"rs-5129432","link":"https://doi.org/10.1007/s00590-025-04257-w","journal":{"identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isVorOnly":false,"title":"European Journal of Orthopaedic Surgery \u0026 Traumatology"},"publishedOn":"2025-04-03 15:57:03","publishedOnDateReadable":"April 3rd, 2025"},"versionCreatedAt":"2024-12-09 13:11:26","video":"","vorDoi":"10.1007/s00590-025-04257-w","vorDoiUrl":"https://doi.org/10.1007/s00590-025-04257-w","workflowStages":[]},"version":"v1","identity":"rs-5129432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5129432","identity":"rs-5129432","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}