Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, South Korea.
Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
Int Orthop. 2018 Dec;42(12):2737-2743. doi: 10.1007/s00264-018-3977-9. Epub 2018 May 31.
Core decompression (CD) has been used to treat early-stage (pre-collapse) osteonecrosis of the femoral head (ONFH) in an attempt to prevent collapse. Recently, other adjunctive treatments including bone grafting (BG) and bone marrow mononuclear cells (BMMC) were combined to traditional CD to improve the results. We assessed the efficacy of various CD modalities and non-operative treatment through a network meta-analysis (NMA).
Nine randomized controlled trials with a minimum two year follow-up were retrieved from PubMed, Embase, and Cochrane Library search. Treatment modalities categorized into five; (1) traditional CD alone, (2) CD combining BG, (3) CD combining BMMC, (4) CD combining BG and BMMC, and (5) non-operative treatment. The rate of conversion to total hip arthroplasty (THA) and the radiologic progression were compared among the five treatments.
A total of 453 hips were included in our NMA; 151 hips in CD, 70 hips in CD combining BG, 116 hips in CD combining BMMC, 25 hips in CD combining BG and BMMC, and 91 hips in non-operative treatment. There were no differences in the rate of THA conversion across all five treatment modalities. The pooled risk ratio compared with non-operative treatment for THA conversion was 0.92 (95% CI, 0.19-4.43; p = 0.915) in traditional CD; 4.10 (95% CI, 0.37-45.42; p = 0.250) in CD combining BG; 0.30 (95% CI, 0.04-2.49; p = 0.267) in CD combining BMMC; and 1.78 (95% CI, 0.05-63.34; p = 0.750) in CD combining BG and BMMC. No significant differences were found in terms of the radiologic progression across all treatments.
In the current NMA, we did not find any differences in the rates of THA conversion and radiologic progression across all CD modalities and non-operative treatment. These results question the assumption that CD changes the natural course of ONFH. Considering that size of necrotic portion is the major determinant of future collapse of the necrotic femoral head and the collapse does not occur in small lesions even without any treatment, a large-scale randomized controlled trial is necessary to confirm the effectiveness of CD.
Level I, meta-analysis.
核心减压（CD）已被用于治疗早期（塌陷前）股骨头坏死（ONFH），以试图预防塌陷。最近，其他辅助治疗方法，包括骨移植（BG）和骨髓单核细胞（BMMC），已与传统 CD 相结合，以改善治疗效果。我们通过网络荟萃分析（NMA）评估了各种 CD 方式和非手术治疗的疗效。
从 PubMed、Embase 和 Cochrane Library 检索到至少随访 2 年的 9 项随机对照试验。治疗方式分为五类：（1）单纯传统 CD；（2）CD 联合 BG；（3）CD 联合 BMMC；（4）CD 联合 BG 和 BMMC；（5）非手术治疗。比较五种治疗方法中髋关节置换术（THA）的转化率和影像学进展。
我们的 NMA 共纳入 453 髋；151 髋接受 CD 治疗，70 髋接受 CD 联合 BG 治疗，116 髋接受 CD 联合 BMMC 治疗，25 髋接受 CD 联合 BG 和 BMMC 治疗，91 髋接受非手术治疗。所有五种治疗方法的 THA 转化率均无差异。与非手术治疗相比，传统 CD 的 THA 转化率的合并风险比为 0.92（95%CI，0.19-4.43；p=0.915）；CD 联合 BG 为 4.10（95%CI，0.37-45.42；p=0.250）；CD 联合 BMMC 为 0.30（95%CI，0.04-2.49；p=0.267）；CD 联合 BG 和 BMMC 为 1.78（95%CI，0.05-63.34；p=0.750）。所有治疗方法的影像学进展均无显著差异。
在当前的 NMA 中，我们没有发现所有 CD 方式和非手术治疗的 THA 转化率和影像学进展之间有任何差异。这些结果对 CD 改变 ONFH 自然病程的假设提出了质疑。考虑到坏死部分的大小是坏死股骨头未来塌陷的主要决定因素，即使没有任何治疗，小病变也不会发生塌陷，因此需要进行大规模的随机对照试验来证实 CD 的有效性。
I 级，荟萃分析。
