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Osteonecrosis of the Femoral Head Treatment

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Osteonecrosis of the Femoral Head Treatment ADVERTIMENT. Lʼaccés als continguts dʼaquesta tesi queda condicionat a lʼacceptació de les condicions dʼús establertes per la següent llicència Creative Commons: http://cat.creativecommons.org/?page_id=184 ADVERTENCIA. El acceso a los contenidos de esta tesis queda condicionado a la aceptación de las condiciones de uso establecidas por la siguiente licencia Creative Commons: http://es.creativecommons.org/blog/licencias/ WARNING. The access to the contents of this doctoral thesis it is limited to the acceptance of the use conditions set by the following Creative Commons license: https://creativecommons.org/licenses/?lang=en UNIVERSITAT AUTÒNOMA DE BARCELONA FACULTAT DE MEDICINA DEPARTAMENT DE CIRUGÍA OSTEONECROSIS OF THE FEMORAL HEAD TREATMENT WITH ADVANCED CELL THERAPY AND BIOMATERIALS IN AN EXPERIMENTAL SHEEP ANIMAL MODEL Report presented by Víctor Barro Ojeda to obtain the degree of Doctor in Surgery and Morphological Sciences. Directors: Dr. Màrius Aguirre Canyadell . Advisor: Dr. Roberto Vélez Villa Dr. Enric Cáceres Palou Dr. Enric Cáceres Palou. Barcelona 2018 This research project has been funded by a grant obtained from La Fundació de la Marató de TV3, with the number 201220-30-31, entitled: Tratamiento de la osteonecrosis de cabeza femoral con terapia celular avanzada y biomateriales en un modelo experimental ovino. Acknowledgments To the Vall d'Hebron Hospital and the Department of Orthopedic Surgery and Traumatology for giving me the necessary support for the development of this study. To Vall d'Hebron Research Institute and the Autonomous University of Barcelona for stimulating research in health professionals. To Dr. Enric Cáceres for agreeing to be part of this thesis as a director and for his contributions and suggestions. To Dr. Marius Aguirre for depositing in my person all the confidence for the development of this work and for the passion he dedicates to his work day by day. To Dr. Roberto Velez, it is difficult to summarize in few lines how grateful I am for your collaboration, unconditional support and for the excellent friendship we have developed over these years. To Alba Lopez for your generosity and for being the co-responsible for both the organization and the development of this project. To the Unit of Experimental Surgery of the VHIR staff members, especially to the veterinarians Marielle, Carla and Marta. For your collaboration in surgeries and animal care. To the research team led by Maria Pau Ginebra of the Universitat Politécnica de Catalunya (UPC), for giving us your knowledge in biomaterials and allowing us to work with your product. To Dr. Ma. Cristina Manzanares for contributing your extensive and recognized experience in histology of bone regeneration. To my colleagues in the Hip Unit: Luis Azorin, Alejandro Hernandez, Diego Collado and Iñaki Mimendia for supporting me and covering my back when I spent time operating animals. To my residents and UAB medical students who collaborated as assistants in the surgery. To Lidia for your love and for being the best life partner. To my parents Mary and Manuel Brothers Manuel y Andres Sister Mariel My reason and life engine Table of Contents INTRODUCTION ....................................................................................................... 13 1. – Osteonecrosis of the femoral head (ONFH) ............................................................... 15 1.1. - Definitions and concepts .......................................................................................... 15 1.2. - Prevalence ................................................................................................................. 16 1.3. - Etiology ..................................................................................................................... 16 2. – Diagnosis of ONFH .................................................................................................... 21 2.1. - Symptoms associated with ONFH ............................................................................. 21 2.2. - Imaging diagnosis of ONFH ....................................................................................... 22 2.2.1. - Plain radiography ................................................................................................... 23 2.2.2. - Magnetic resonance imaging (MRI) ....................................................................... 26 2.2.3. - Computed tomography (CT) .................................................................................. 28 2.2.4. - Bone scanning ........................................................................................................ 30 2.2.5 Positron emission tomography (PET) scan. ............................................................... 31 3. - Classification systems of ONFH .................................................................................. 32 3.1. - Ficat Classification ..................................................................................................... 32 3.2. - ARCO Classification ................................................................................................... 33 3.3. - Radiographic Classification System of the Japanese Orthopedic Association .......... 34 3.4. - University of Pennsylvania Classification and Staging System .................................. 35 3.5. - Steinberg Classification ............................................................................................. 36 4. - Pathogenesis ............................................................................................................. 37 5. - Clinical entities commonly associated to ONFH ......................................................... 42 6. - Management of ONFH ............................................................................................... 53 6.1. - Nonsurgical management of ONFH .......................................................................... 54 6.2. - Biophysical management of ONFH ........................................................................... 57 6.2. - Surgical management of ONFH ................................................................................. 58 7. - Experimental animal models of ONFH ....................................................................... 65 7.1. - Trauma-induced ONFH experimental models .......................................................... 66 7.2. - Experimental models of ONFH with non-traumatic agents ...................................... 69 8. - Biological treatments of ONFH .................................................................................. 73 8.1. - Stem cell therapy ...................................................................................................... 73 8.2. - Intra-arterial injection of stem cells .......................................................................... 77 8.3. - Bioactive molecules .................................................................................................. 79 8.4. - Platelet-rich plasma .................................................................................................. 82 HYPOTHESIS AND OBJECTIVES ................................................................................. 85 9. -Hypothesis ................................................................................................................. 87 10. - Objectives ............................................................................................................... 87 MATERIAL AND METHODS ...................................................................................... 89 11- Material .................................................................................................................... 91 11.1 Animal ........................................................................................................................ 91 11.2 Osteonecrosis of the femoral head (ONFH) induction material ................................ 93 12- Methods ................................................................................................................... 96 12.1 Anesthetic protocol .................................................................................................... 96 12.2 Femoral head osteonecrosis (FHO) induction technique: .......................................... 98 12.3 Core Decompression technique: .............................................................................. 100 12.4 Clinical Evaluation .................................................................................................... 105 12.5 Euthanasia protocol ................................................................................................. 106 12.6 Micro CT Scan evaluations: ...................................................................................... 108 12.7 Biomechanical evaluations ....................................................................................... 110 12.8 Histological technique: ............................................................................................. 112 RESULTS ................................................................................................................ 119 13. - Clinical Results ....................................................................................................... 121 13.1 Weight ...................................................................................................................... 121 13. -2 Complications: ......................................................................................................
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