J Korean Orthop Assoc.  2008 Feb;43(1):1-8. 10.4055/jkoa.2008.43.1.1.

Clinical Results of Autoiliac Cancellous Bone Graft Combined with Implantation of Autologous Bone Marrow Cells for Osteonecrosis of the Femoral Head

• Kang JS
• Moon KH
• Park SR
• Kang SB
• Park HB
• Lee SH

• KMID: 2106409
• DOI: http://doi.org/10.4055/jkoa.2008.43.1.1

Abstract

PURPOSE: We prospectively analyzed the clinical results of auto-iliac cancellous bone graft with autologous bone marrow mononucleated cell implantation for osteonecrosis of the femoral head.
MATERIALS AND METHODS
In a prospective evaluation, 45 hips in 37 patients with osteonecrosis of the hip were treated with auto-iliac cancellous bone graft after core decompression combined with implantation of autologous bone marrow cells. The average duration of clinical follow up of the patients was 32 months. Core decompression of the femoral head was performed and most of the necrotic part of the head was removed. Auto-iliac cancellous bone grafting was then done to fill up the defect, and this was followed by cell therapy with implantation of autologous monocytes isolated from the iliac bone marrow.
RESULTS
The mean Merle d' Aubigne and Postel score improved from 11.6 points preoperatively to 15.5 points. Collapse of the femoral head developed in 13 hips, of which 12 hips showed an extensive lesion on the preoperative radiogram. Total hip replacement surgery was performed in 9 hips: 8 hips were due to progressive collapse of the femoral head with clinical deterioration, and 1 hip was due to postoperative bacterial infection. The preoperative stages of the 8 hips that were converted to THRA were stage II in 1 hip, stage III in 4 hips and stage IV in 3 hips. The head preservation rate according to the preoperative stage was 94.4% in stage II, 77.8% in stage III and 66.7% in stage IV.
CONCLUSION
Auto-iliac cancellous bone grafting combined with implantation of autologous bone marrow cells after core decompression showed a good clinical results on the short term follow-up. Long term follow-up studies are still necessary to validate this point.

Keyword

Hip; Osteonecrosis; Bone marrow implantation; Bone graft

MeSH Terms

Arthroplasty, Replacement, Hip
Bacterial Infections
Bone Marrow
Bone Marrow Cells
Bone Transplantation
Decompression
Follow-Up Studies
Head
Hip
Humans
Monocytes
Osteonecrosis
Prospective Studies
Tissue Therapy
Transplants

Figure

• 

  Fig. 1 (A, B) Preoperative plain radiographs and MRI of 45-year-old male patient shows large osteonecrosis of left femoral head. (C) At 1 year after surgery, crescent sign was found. (D) Radiograph of postoperative 3 years shows the change of head contour and head depression less than 1 mm. However, he did not have any difficulty in activity and clinical result was excellent.

• 

  Fig. 2 (A, B) A radiography and an MRI of a 32-year-old male patient showed alcohol-induced osteonecrosis of stage III (severe lesion). (C) Postoperative 6 months radiograph shows minimal change of head contour and crescent sign. (D) Radiograph of postoperative 28 months shows the head depression about 1 mm. However, he can do full ordinary activity without pain.

Reference

1. Camp JF, Colwell CW Jr. Core decompression of the femoral head for osteonecrosis. J Bone Joint Surg Am. 1986. 68:1313–1319.

2. Merle D'Aubigne R, Postel M, Mazabraud A, Massias P, Gueguen J, France P. Idiopathic necrosis of femoral head in adults. J Bone Joint Surg Br. 1965. 47:612–633.

3. Engh CA, Gloss FE, Bobyn JD. Biologic fixation arthroplasty in the treatment of osteonecrosis. Orthop Clin North Am. 1985. 16:771–787.

4. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br. 1985. 67:3–9.

5. Ficat RP, Arlet J. Ischemia and necrosis of bone. 1980. Boltimore, London: Williams and Wilkins.

6. Ficat RP, Arlet J. Hungerford DS, Mont MA, editors. Treatment of bone ischemia and necrosis. Ischemia and necrosis of bone. 1980. Baltimore: Williams & Wilkins;171–182.

7. Gangji V, Hauzeur JP, Matos C, De Maertelaer V, Toungouz M, Lambermont M. Treatment of osteonecrosis of the femoral head with implantation of autologous bone marrow cells. A pilot study. J Bone Joint Surg Am. 2004. 86:1153–1160.

8. Gangji V, Hauzeur JP, Schoutens A, Hinsenkamp M, Appelboom T, Egrise D. Abnormalities in the replicative capacity of osteoblastic cells in the proximal femur of patients with osteonecrosis of the femoral head. J Rheumatol. 2003. 30:348–351.

9. Gardeniers JW. A new international classification of osteonecrosis of the ARCO-committee on terminology and classification. ARCO News. 1992. 4:41–46.

10. Hernigou P, Beaujean F. Abnormality in the bone marrow of the iliac crest in patients who have necrosis secondary to corticosteroid therapy or alcohol abuse. J Bone Joint Surg Am. 1997. 79:1047–1053.

11. Hernigou P, Beaujean F. Treatment of Osteonecrosis With Autologous Bone Marrow Grafting. Clin Orthop Relat Res. 2002. 405:14–23.

12. Hernigou P, Bachir D, Galacteros F. The natural history of symptomatic osteonecrosis in adults with sickle-cell disease. J Bone Joint Surg Am. 2003. 85:500–504.

13. Hernigou P, Beaujean F, Lambotte JC. Decrease of mesenchymal stem-cell pool in the proximal femur in cokticosteroid induced osteonecrosis. J Bone Joint Surg Br. 1999. 81:349–355.

14. Hungerford DS, Mont MA. Urbaniak JR, Jones JP, editors. The Role of Core Decompression in the Treatment of Osteonecrosis of the Femoral Head. Osteonecrosis: etiology, diagnosis and treatment. 1997. Rosemont, IL: American Academy of Orthopaedic Surgeons;287–292.

15. Hungerford DS, Zizic TM. Pathogenesis of ischemic necrosis of the femoral head. The hip proceeding of the eleventh open scientific meeting of The Hip Society. 1983. ST Louis, Toronto: CV Mosby;219–262.

16. Katz RL, Bourne RB, Rorabeck CH, McGee H. Total hip arthroplasty in patients with avascular necrosis of the hip. Follow-up observations on cementless and cemented operations. Clin Orthop Relat Res. 1992. 281:145–151.

17. Koo KH, Kim R, Ko GH, Song HR, Jeong ST, Cho Sh. Preventing collapse in early osteonecrosis of the femoral head. A randomized clinical trial of core decompression. J Bone Joint Surg Br. 1995. 77:870–874.

18. Launder WJ, Hungerford DS, Jones LH. Hemodynamics of the femoral head. J Bone and Joint Surg Am. 1981. 63:442–448.

19. Marcus ND, Enneking WF, Massam RA. The silent hip in idiopathic aseptic necrosis: Treatment by bone grafting. J Bone Joint Surg Am. 1973. 55:1351–1366.

20. Merle d'Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954. 36:451–475.

21. Mont MA, Etienne G, Ragland PS. Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2003. 417:84–92.

22. Mont MA, Marulanda GA, Seyler TM, Plate JF, Delanois RE. Core decompression and nonvascularized bone grafting for the treatment of early stage osteonecrosis of the femoral head. Instr Course Lect. 2007. 56:213–220.

23. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995. 77:459–474.

24. Mont MA, Jones LC, Sotereanos DG, Amstutz HC, Hungerford DS. Understanding and treating osteonecrosis of the femoral head. Instr Course Lect. 2000. 49:169–185.

25. Park HC, Shim YS, Ha Y, et al. Treatment of complete spinal cord injury patients by autologous bone marrow cell transplantation and administration of granulocyte-macrophage colony stimulating factor. Tissue Eng. 2005. 11:913–922.

26. Rijnen WH, Gardeniers JW, Buma P, Yamano K, Slooff TJ, Schreurs BW. Treatment of femoral head ostenecrosis using bone impaction grafting. Clin Orthop Relat Res. 2003. 417:74–83.

27. Steinberg ME, Bands RE, Parry S, Hoffman E, Chan T, Hariman KM. Does lesion size affect the outcome in avascular necrosis. Clin Orthop Relat Res. 1999. 367:262–271.

28. Steinberg ME, Larcom PG, Strafford B, et al. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2001. 386:71–78.

29. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br. 1995. 77:34–41.

30. Stulberg BN, Davis AW, Bauer TW, L'evien M, Easley K. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop Relat Res. 1991. 268:140–151.

31. Suh KT, Kim SW, Roh HL, Youn MS, Jung JS. Decreased osteogenic differenciation of mesenchymal stem cells in alchol-induced osteonecrosis. Clin Orthop Relat Res. 2005. 431:220–225.

32. Yoon TR, Song EK, Rowe SM, Park CH. Failure after core decompression in osteonecrosis of femeral head. Int Orthop. 2001. 24:316–318.