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Stage-Related Results in Treatment of Hip Osteonecrosis with Core-Decompression and Autologous Mesenchymal Stem Cells

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Stage-Related Results in Treatment of Hip Osteonecrosis with Core-Decompression and Autologous Mesenchymal Stem Cells Acta Orthop. Belg., 2015, 81, 406-412 ORIGINAL STUDY Stage-related results in treatment of hip osteonecrosis with core-decompression and autologous mesenchymal stem cells Pietro PERSIANI, Claudia DE CRISTO, Jole GRACI, Giovanni NOIA, Michele GURZÌ, Ciro VILLANI From Universitary Department of Anatomic, Histologic, Forensic and Locomotor Apparatus Sciences, Section of Locomotor Apparatus Sciences, Policlinico Umberto I, Sapienza University of Rome Our aim is to analyse the clinical outcome of a series thetic hip replacement. Therapy with glucocorti- of patients affected by avascular necrosis of the femo- coids and alcohol abuse are some of the main known ral head and treated with core-decompression tech- causative factors (21). Several pathophysiological nique and autologous stromal cells of the bone mechanisms were formulated about this pathology, marrow. including fat emboli, microvascular occlusion of We enrolled in our study 29 patients with 31 hips in epiphysis vessels and micro fracture of trabecular total affected by avascular necrosis of the femoral 13,18 head. bone ( ). An early diagnosis and a continuous The clinical and radiological outcome has been monitoring of patients with risk factors (corticoste- assessed through self-administered questionnaires roids therapy, alcoholism, or irradiated patients) are (HHS, VAS and SF12) X-ray and Magnetic Reso- very important in order to highlight the AVNFH nance. typical alteration as early as possible. Of all the examined hips, 25 showed a relief of the The treatment of osteonecrosis is one of the most symptoms and a resolution of the osteonecrosis, 11 of controversial subjects in the orthopaedic literature. these were at Stage I and 14 at Stage II. The progres- sion of the disease occurred in 6 hips (2 Stage II, 2 Stage III and 2 Stage IV). Our results show a significant decrease in joint pain level and a success in avoiding or delaying the need of n hip replacement in early stages of osteonecrosis. Pietro Persiani, MD, PhD, Orthopaedic Surgeon. n Claudia De Cristo, MD. Keywords : hip osteonecrosis ; stromal cells ; femoral n Jole Graci, MD. head. n Giovanni Noia, MD. n Michele Gurzì. MD, Orthopaedic Resident. n Ciro Villani, MD, Orthopaedic Surgeon, Professor of Ortho- paedic Surgery. INTRODUCTION Department of Orthopaedics and Traumatology, Policlinico Umberto I, ‘‘Sapienza’’ University of Rome, Piazzale Aldo Moro 5, Rome, Italy. Avascular bone necrosis of the femoral head Correspondence : Claudia De Cristo, Department of Ortho- (AVNFH) mainly affects young adults within their paedics and Traumatology, Policlinico Umberto I, ‘‘Sapienza’’ third, fourth or fifth decade of life and it has a large University of Rome, Piazzale Aldo Moro 5, Rome, Italy. impact on life quality. Its progression can lead to E-mail : [email protected] © 2015, Acta Orthopædica Belgica. hip joint impairment, and up to the need of pros- No benefits or funds were received in support of this study. Acta Orthopædica Belgica, Vol. 81 - 3 - 2015 The authors report no conflict of interests. persiani-.indd 406 21/09/15 08:21 HIP OSTEONECROSIS WITH CORE-DECOMPRESSION AND AUTOLOGOUS MESENCHYMAL STEM CELLS 407 Several parameters need to be examined, such as average follow-up time was 37 months (range from 23 to age, medical history, need for continued cortisone 48 months). The average age of the patients was 34 years therapy, presence of necrosis of the other hip and (range 26-53 years) at time of surgery. Of the 29 patients, size of the necrotic area. In the stage I of the disease, 16 were men and 13 were women. Staging of osteonecro- non-operative procedures such as non-weight bear- sis was determined according to Steinberg classifica- tion (28). At the time of surgery, 11 out of a total of ing, pharmacological, hyperbaric, or oxygen thera- 31 hips were at Stage I, 16 at Stage II, 2 at Stage III, 2 at py, and the use of pulsed electromagnetic fields are Stage IV. As for the etiology of the AVNFH, 7 hips were all accepted. Operative treatments for stage II in- affected by idiopathic osteonecrosis, 2 of which were at clude core decompression, tantalum rod, trapdoor Stage I and 5 at Stage II. 18 hips were affected by osteo- procedure, vascularized fibular graft, osteotomy, necrosis due to corticosteroid therapy (14 monolateral and non-vascularized bone grafting. Stages III and and 2 with bilateral involvement), 6 of which at Stage I IV present a wide involvement of the femoral head and 9 at Stage II, 1 at Stage III and 2 at Stage IV. 6 hips that often leads to hip resurfacing or total hip arthro- were affected by osteonecrosis due to alcoholism, 3 of plasty. which at Stage I, 2 at stage II and 1 at stage III (Table I). Core decompression (CD) is the most frequently All patients were treated from 2006 to 2010 with core adopted method for early AVNFH treatment (1,27). decompression and implantation of autologous mesen- It removes the necrotic area and decreases intraos- chymal stromal cells of the bone marrow, harvested from iliac crest. Fibroblast colony forming units (F-CFU) was seus pressure, improving venous return and promot- used to assess the number of grafted mesenchymal stro- ing vascularisation of the necrotic area of the femo- mal cells, calculated on the number of nucleated cells (9). ral head. Nevertheless, various studies about the The average F-CFU was 1390/cm3 with a range from effectiveness of this technique showed a wide range 1160 to 1520/cm3. of results. One of the possible reasons of its failure Our study examined several aspects of the clinical pre- is that a single CD does not induce an adequate os- sentation and the pathologic features through : recording teogenic activity in the necrotic area (15,16,32). In of haematological and inflammatory indices, pre-opera- literature, a large number of studies proved the con- tive and long term radiographic evaluation according to nection between AVNFH and a decreasing number Steinberg classification (28), VAS, as well as Harris Hip of bone mesenchymal staminal cells (MSC) with Score (24) and SF12 (11) questionnaires to assess hip func- low proliferative activity. The replication ability of tion, pain and quality of life of our patients. Scorings the bone progenitor cells decreases in proximal were registered preoperatively, and every year after the treatment. The radiographic assessment focussed on the femoral epiphysis of patients affected by AVNFH. progression in radiographic stages, on the presence of Consequently, approach to AVNFH treatment bone-neoformation and on the absence or presence of seems to be more appropriate if an autologous bone femoral head collapse. Clinical and radiographic follow- marrow implantation is performed after core de- up evaluations were made at 1 month, 6 months and compression, in order to provide osteogenic precur- every year after surgery. Additional controls with sors to the necrotic area (17). Magnetic Resonance Images were performed at 6 months We studied a series of 29 patients with a diagno- after surgery and every year afterwards. sis of AVNFH who were treated with CD technique Surgical technique followed the P. Hernigou operative and bone marrow implantation. Our aim is to inves- technique : aspiration of autologous bone marrow, isola- tigate, in a retrospective view, the rate and thus the tion and concentration of aspirated marrow, core decom- efficiency of the treatment we used according to the pression, grafting of the concentrated cells (14). With the gravity of AVNFH stage of our case series. patient under general anaesthesia, a skin incision of 5 mm was made at the level of the upper margin of the anterior superior iliac crest, and a needle tip (11 cm, 11 MATERIALS AND METHODS gauge) was introduced for about 6 cm until the spongy bone was reached between outer and inner tables. The We conducted a retrospective clinical study based on needle tip was removed and a sterile syringe of 25 ml a case series of 29 patients affected by avascular osteo- (containing 3 ml of heparin) was introduced for the exe- necrosis of the femoral head, with 31 hips in total. The cution of short marrow aspirations of 3-5 ml with the aim Acta Orthopædica Belgica, Vol. 81 - 3 - 2015 persiani-.indd 407 18/09/15 09:49 408 P. PERSIANI, C. DE CRISTO, J. GRACI, G. NOIA, M. GURZÌ, C. VILLANI Table I. — Etiology and Stage No. of patients (hips) Etiology Stage I Stage II Stage III Stage IV 7 Idiopathic 2 5 – – 16 (18) Corticosteroid use 6 9 1 2 6 Alcohol abuse 3 2 1 – of optimizing the removal of MSC. After each aspiration strengthen gluteus and quadriceps muscles and to prevent in one site, the needle performed a full circle in steps of tendon and muscular retractions or harmful postural 45°. At the end of each complete 360° needle revolution, changes. it was moved 1 cm higher or lower in the cancellous Wilcoxon test was performed to assess differences in bone, and then the whole procedure was repeated until HHS, VAS and SF12 indices after treatment, according 50 cc of bone marrow were harvested (two syringes). to the different staging groups. A binomial test was used Concentration of the aspirated marrow was performed to assess the significance of the success of the treatment. through the MarrowStim™ centrifuge system, at We considered statistically significant values of p < 0.05. 3200 RPM for 15 minutes. This system can separate up Data are expressed in the form mean value ± standard to 50 cc of bone marrow, concentrating mononucleated deviation. Data have been analysed in the statistical soft- and polinucleated cells within a volume of 6 cc of con- ware SPSS 19. centrated marrow. The procedure is performed directly in the operating room during the same surgery time.
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