Core decompression | osteonecrosis | avascular necrosis
In this article Ross Hauser, MD discusses new research on bone repair in osteoarthritis
Osteonecrosis (called avascular necrosis or aseptic necrosis) is a condition where blood supply to the bone is impeded or disrupted. Bone needs circulating blood to regenerate and repair, without blood flow the bone dies. In the hip this is a leading cause of the degenerative condition and the need for hip replacement surgery.One treatment option is core decompression. This surgical procedure involves drilling a hole(s) into the femoral head of the hip to relieve pressure in the bone and hopefully create new blood vessels to nourish the affected areas of the hip. The overall success of this treatment is unclear.
A research team from Canada and the United Kingdom issued troubling findings in patients where core decompression failed and a subsequent total hip replacement was required.
The doctors looked at core decompression and insertion of a tantalum rod into the hip joint for stabilization. The doctors were concerned that there may be a high failure rate associated with this procedure and examined failed tantalum rod insertion patients and their move to and subsequent hip replacement outcomes.
They found that in the short term, tantalum rod implantation does not adversely effect subsequent total joint replacement surgery. HOWEVER, patients show a high rate of retained tantalum debris on post-operative radiographs and thus there is an unknown risk of accelerated articular wear necessitating longer term study.1 Common sense should tell us floating metallic debris in the hip is not optimum and reminds many of the metal on metal hip replacement recalls.
Doctors in China shared their equal concerns: “Porous tantalum osteonecrosis implants have been used in femoral head necrosis for several years, while the clinical outcomes were mixed. As a joint-preserving surgery, early necrosis deterioration and conversion to total hip replacement failed our expectation.”2
One of the concerns of the Chinese researchers was how fast the surgery failed and caused stress fractures in the bone it was designed to preserve.
Using Statins to Preserve the Hip
Another Chinese research team looked at solving the problem of core decompression outcome failure by introducing the statin Simvastatin into the surgery because the drug has demonstrated the ability to promote bone formation and reduce bone adsorption.3
Other surgeons however are more eager to incorporate PRP Platelet Rich Plasma and Stem Cells into this surgical procedure. In one study the surgeons reported core decompression worked very well when PRP was injected arthroscopically.4
In another recent study researchers suggest that the application of autologous bone marrow stem cell concentrate in combination with core decompression in osteonecrotic femoral heads is superior to core decompression treatment alone, as it was found to markedly decelerate the progression of the disease to the stage of femoral head collapse, and also limit the need for total hip replacement.5
But shouldn’t stem cells be tried before the core decompression procedure?
Writing in the Journal of Prolotherapy, we documented the first case report of using direct bone marrow aspiration into areas of pain in a patient with avascular necrosis of the talus that does not involve core decompression. In this particular case, the bone marrow aspirate was injected into the tibiotalar and subtalar joints. The surrounding painful and injured ligaments on the lateral and medial sides of the ankle were also treated with Prolotherapy. Treating avascular necrosis with bone marrow stem cells is definitely a viable and successful treatment option to explore prior to surgery.
The use of stem cell therapy in bone necrosis is exciting
The use of stem cell therapy in bone necrosis is exciting. In the more than two decades experience we have working with patients in varying degrees of osteoarthritis, nothing sounds more terminal and ominous than the patient being told by another doctor that their bone is dying or they have necrosis dead bone cells. Probably no other diagnosis leads to a quicker joint replacement than “bone death.”
The diagnosis of avascular necrosis should not mean automatic joint replacement, nor should its diagnosis need to be a “life-altering situation” in many cases it can be managed with the comprehensive approach of dextrose Prolotherapy, Platelet Rich Plasma, and Stem Cell Therapy.
In April 2015 doctors reported exciting news about stem cell therapy as a new modality of treatment in bone lesions that could not be treated with autologous bone grafting. However, while successful results were reported from individual studies, the researchers said more studies were needed to validate stem cell therapy injections, an established treatment for bone regeneration.6
- Since the time of that paper, validation has come from dozens of papers.Doctors writing in the European review for medical and pharmacological sciences had this to say over a seemingly new weapon surgeons could use to make surgery more successful.
Application of ‘regenerative medicine’ has given a new hope to surgeons for the treatment of several chronic diseases and disorders including severe orthopedic conditions. There are a myriad of orthopedic conditions and injuries that presently have limited therapeutic treatments and could benefit from new developing therapies in regenerative medicine with the help of stem cell therapy
Stem cells play a vital role in orthopedic treatments and the studies have shown to have promising results in repair of bone, tendon, cartilage including avascular necrosis, spondylitis etc.7
In other research doctors confirmed that stem cell therapy for bone regeneration worked outside of surgery.
This was acknowledged in November 2015: Researchers in China reviewing the use of mesenchymal stem cells say stem cells may be a primary way used to cure bone injury and other woundings in the near future.8
- Doctors find that a combination of adipose-derived mesenchymal stem cells and Platelet Rich Plasma regenerated bone mineral matrix in animal model (regrew bone).9 This was reconfirmed in reported animal studies – researchers found that Fat (adipose) based MSC and PRP stimulated the articular extracellular matrix and reduced damaging inflammation in dogs with osteoarthritis.10
- Researchers examined the problems of bone deformities. (Distraction osteogenesis or expanded bone growth). They tested bone growth using either a combination of stem cells and Platelet Rich Plasma Therapy or Platelet Rich Plasma Therapy alone. They found the combination of stem cell therapy and platelet rich plasma therapy provided superior results for accelerated bone growth.11
In an animal study, doctors examined stem cells for bone regrowth in the jaw bones of rats who had bisphosphonate-related osteonecrosis (Bisphosphonates, when administered intravenously for the treatment of cancer, have been associated with osteonecrosis of the jaw). They found adipose-derived mesenchymal stem cells provided significant bone regrowth.12
In another interesting new paper, researchers found Resveratrol, the natural antioxidant and anti-inflammatory found in the skins of grape seeds and other plants and made famous for red wine’s seemingly heart and cancer preventative benefits, when introduced in stem cell therapy, promoted accelerated bone growth by helping to regulate inflammation on bone defects.13
Bone death – Avascular necrosis (AVN), osteonecrosis, aseptic necrosis, or ischemic bone necrosis can develop many ways. Ironically, corticosteroids, a treatment designed to assist in managing chronic joint pain is a leading culprit. Many researchers have speculated that possibly one-third of non-traumatic AVN is caused by corticosteroids abuse. Worse, it may not take that many cortisone shots to begin the destructive process. If co-risk factors exist, the dangers are that much greater.
Doctors note that case reports in patients who “hardly” used corticosteroids who are now developing osteonecrosis are of great concern to physicians.14
The standard treatments for AVN seemingly lead to a singular destiny – joint replacement. But are there realistic options? Case studies started to appear in the medical literature which explore Platelet Rich Plasma and Stem Cell Therapy as possible solutions to bone death.
In one case PRP was found incredible effective for advanced-stage degenerative AVN of the hip, with the patient demonstrating significant functional improvements and the ultimate outcome of being able to avoid surgery.15
In our own clinical experiences we have seen similar results in patients who were given two options only – bilateral core decompression surgery or bilateral total hip replacement surgery. Patients should have been given the non-surgical option.
References for this article
1. Olsen M, Lewis PM, Morrison Z, McKee MD, Waddell JP, Schemitsch EH. Total hip arthroplasty following failure of core decompression and tantalum rod implantation. Bone Joint J. 2016 Sep;98-B(9):1175-9.
2. Zhang X, Wang J, Xiao J, Shi Z. Early failures of porous tantalum osteonecrosis implants: a case series with retrieval analysis. Int Orthop. 2016 Sep;40(9):1827-34.
3. Yin H, Yuan Z, Wang D. Multiple drilling combined with simvastatin versus multiple drilling alone for
the treatment of avascular osteonecrosis of the femoral head: 3-year follow-up study. BMC Musculoskelet Disord. 2016 Aug 15;17(1):344.
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7. Li Y1, Tang J, Hu Y, Peng YH, Wang JW. A study of autologous stem cells therapy assisted regeneration of cartilage in avascular bone necrosis. Eur Rev Med Pharmacol Sci. 2015 Oct;19(20):3833-7.
8. Shao J, Zhang W, Yang T. Using mesenchymal stem cells as a therapy for bone regeneration and repairing. Biol Res. 2015 Nov 3;48(1):62. doi: 10.1186/s40659-015-0053-4.
9. Cvetković VJ, Najdanović JG, Vukelić-Nikolić MĐ, Stojanović S, Najman SJ. Osteogenic potential of in vitro osteo-induced adipose-derived mesenchymal stem cells combined with platelet-rich plasma in an ectopic model. Int Orthop. 2015 Aug 1. [Epub ahead of print]
10. Yun S, Ku SK, Kwon YS. Adipose-derived mesenchymal stem cells and platelet-rich plasma synergistically ameliorate the surgical-induced osteoarthritis in Beagle dogs. J Orthop Surg Res. 2016 Jan 15;11(1):9. doi: 10.1186/s13018-016-0342-9.
11. Dehghan MM, Baghaban Eslaminejad M, Motallebizadeh N, Ashrafi Halan J, Tagiyar L, Soroori S, Nikmahzar A, Pedram M, Shahverdi A, Kazemi Mehrjerdi H, Izadi S. Transplantation of Autologous Bone Marrow Mesenchymal Stem Cells with Platelet-Rich Plasma Accelerate Distraction Osteogenesis in A Canine Model. Cell J. 2015 Summer;17(2):243-52. Epub 2015 Jul 11.
12. Barba-Recreo Pet al. Adipose-derived stem cells and platelet-rich plasma for preventive treatment of bisphosphonate-related osteonecrosis of the jaw in a murine model. J Craniomaxillofac Surg. 2015 May 9. pii: S1010-5182(15)00132-8. doi: 10.1016/j.jcms.2015.04.026. [Epub ahead of print]
13. Zhang A, Zhang X, Tan X, Cai B, Ge W, Dai G, Cai J. Resveratrol rescued the TNF-α-induced impairments of osteogenesis of bone-marrow derived mesenchymal stem cells and inhibited the TNF-α-activated NF-кB signaling pathway. Int Immunopharmacol. 2015 Jun;26(2):409-15. doi: 10.1016/j.intimp.2015.04.026. Epub 2015 Apr 25.
14. Weldon D. The effects of corticosteroids on bone: osteonecrosis (avascular necrosis of the bone). Ann Allergy Asthma Immunol. 2009 Aug;103(2):91-7; quiz 97-100, 133. doi: 10.1016/S1081-1206(10)60159-7.
15. Ibrahim V, Dowling H. Platelet-rich plasma as a nonsurgical treatment option for osteonecrosis. PM R. 2012 Dec;4(12):1015-9. doi: 10.1016/j.pmrj.2012.07.009.