Proof of concept to portray management of early and mid-stage avascular necrosis with bone marrow aspirate concentrate and high concentrate plasma augmentation, post percutaneous core decompression-an ortho biologics approach

Venkatesh Movva; Anand Alluru; Syed Khaleel; Sunitha Manne Mudhu; Vijayalakshmi Venkatesan

doi:10.18203/issn.2455-4510.IntJResOrthop20260506

Authors

Venkatesh Movva RegenOrthoSport, Movva Health Care LLP, Jubilee Hills, Hyderabad, Telangana, India
Anand Alluru RegenOrthoSport, Movva Health Care LLP, Jubilee Hills, Hyderabad, Telangana, India
Syed Khaleel RegenOrthoSport, Movva Health Care LLP, Jubilee Hills, Hyderabad, Telangana, India
Sunitha Manne Mudhu Regenerative Research Sciences Pvt Ltd, AIC-CCMB, Biotechnology Complex, IDA Uppal, Hyderabad, Telangana, India
Vijayalakshmi Venkatesan Regenerative Research Sciences Pvt Ltd, AIC-CCMB, Biotechnology Complex, IDA Uppal, Hyderabad, Telangana, India

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20260506

Keywords:

Avascular necrosis, Femoral head, Bone marrow concentrate, Platelet-rich plasma, Percutaneous core decompression

Abstract

Background: Avascular necrosis (AVN) or osteonecrosis of the femoral head portray as a progressive disease affecting hip joints particularly in younger and middle-aged individuals and if left untreated precipitate to secondary complications. Percutaneous core decompression (PCD) has been the first line treatment for AVN in view of its beneficial effects to remove necrotic lesion, non-invasive, compression lessened with revascularization. Ortho biologics explore the application of autologous bone marrow aspirate concentrate (BMAC) and high concentrate platelet rich plasma (HCP) found naturally in body to improve healing, reduce inflammation with very good safety profile and require minimal post-procedural time for recovery. Present study explores the synergistic effect of autologous BMAC and HCP post PCD, as an interventional therapy to treat AVN patients.

Methods: We recruited (prospective study) 45 AVN patients (mean age: 37.8 years, range, 15-52 years, 38 males and 7 females). Treatment included PCD followed by augmentation with autologous BMAC and HCP injection via fluoroscopy in femoral head guided. The patient’s follow-up was for two years by telephonic survey post therapy (2023-2025) and were assessed using standard Ficat and Arlet scoring.

Results: Patients in stage I (3.8%), stage II (55.7%) and stage III (16.45%) showed greater improvement(s) as very good/good/satisfactory compared to stage IV (12.65%) which required total hip replacement (THR).

Conclusions: We advocate promising line of treatment for management of stage I-III of AVN patients (Ficat and Arlet scoring) using combination of BMAC and HCP augmentation post PCD.

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References

Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Osteonecrosis of the femoral head: Potential treatment modalities. J Am Academy Orthop Surg. 2020; 28(3):117-30.

Zhao D, Zhang F, Wang B, Liu B, Li L, Kim SY, et al. Osteonecrosis of the femoral head: Etiology, imaging, and treatment. Arthritis Res Therapy. 2021;23:45.

Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. Pathogenesis and natural history of osteonecrosis. Seminars Arthrit Rheumat. 2002;32(2):94-124. DOI: https://doi.org/10.1053/sarh.2002.33724b

Ficat RP, Arlet J. Ischemia and necrosis of bone.In: Hungerford DS (Ed.), The Hip, Baltimore: Williams and Wilkins. 1980;171-82.

Steinberg ME, Hayken GD, Steinberg DRA quantitative system for staging avascular necrosis. J Bone Joint Surg. 195;77(1):34-41. DOI: https://doi.org/10.1302/0301-620X.77B1.7822393

Sroujia S, Livneb E. Bone marrow stem cells and biological scaffold for bone repair in aging and disease. Mech Age Dev. 2005;126:281-7. DOI: https://doi.org/10.1016/j.mad.2004.08.031

Hernigou P, Beaujean F, Lambotte JC. Decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroid-induced osteonecrosis. J Bone Joint Surg. 1999;81:349-55. DOI: https://doi.org/10.1302/0301-620X.81B2.0810349

Hernigou P, Manicom O, Poignard A, Nogier A, Filippini P, Abreu LD. Core decompression with marrow stem cells. Oper Tech Orthop. 2004;14:68-74. DOI: https://doi.org/10.1053/j.oto.2004.03.001

Rao SK, Venkatesan V. Prevention of Femoral Head Collapse In Osteonecrosis of Femoral Head by Core Decompression and Autologous Bone Marrow Aspirate Concentrate. J Dental Med Sci. 2016;15(2):50-5.

Kotikalapudi N, Sampath SJ, Sukesh Narayan S, Ramesh R B, Nemani H, Mungamuri SK, Vijayalakshmi V. The promise (s) of mesenchymal stem cell therapy in averting preclinical diabetes: lessons from in vivo and in vitro model systems. Scientific Rep. 2021;11(1):1-8. DOI: https://doi.org/10.1038/s41598-021-96121-0

Arbeloa-Gutierre L. Core Decompression Augmented with Autologous Bone Marrow Aspiration Concentrate for Early Avascular Necrosis of the Femoral Head. Arthros Tech. 2016;5(3):615-20. DOI: https://doi.org/10.1016/j.eats.2016.02.009

Movva V, Venkatesan V, Khaleel S, Manne S, Swetha B, Balakrishna N. Therapeutic Efficacy Of Bone Marrow Aspirate And Platelet Enriched Plasma (Autologous) Studied In Osteoarthritic Patients-Proof Of Concept Study. 2023;12:13.

Jo CH, Lee YG, Shin WH, Kim H, Chai JW, Jeong EC, et al. Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial. Stem Cells. 2014;32:1254-66. DOI: https://doi.org/10.1002/stem.1634

Kouroupis D, Ahari AF, Correa D, Shammaa R. Intralesional injection of bone marrow aspirate concentrate for the treatment of osteonecrosis of the knee secondary to systemic lupus Erythematosus: a case report. Front Bioeng Biotechnol. 2020;8:202-5. DOI: https://doi.org/10.3389/fbioe.2020.00202

Kim JD, Lee GW, Jung GH, Kim CK, Kim T, Park JH, et al. Clinical outcome of autologous bone marrow aspirates concentrate (BMAC) injection in degenerative arthritis of the knee. Eur J Orthop Surg Traumatol. 2014;24:1505-11. DOI: https://doi.org/10.1007/s00590-013-1393-9

Kon E, Buda R, Filardo G, Di Martino A, Timoncini A, Marcacci M. Platelet-rich plasma: Intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):174-83.

Hede K, Christensen BB, Jensen J, Foldager CB, Lind M. Combined Bone Marrow Aspirate and Platelet-Rich Plasma for Cartilage Repair: Two-Year Clinical Results. Cartilage. 2021;13(1):937-47. DOI: https://doi.org/10.1177/1947603519876329

Cole BJ, Karas V, Hussey K. Hyaluronic acid versus plateletrich plasma: a prospective, double-blind randomized controlled trial comparing clinical outcomes and effects on intra-articular biology for the treatment of knee osteoarthritis. Am J Sports Med. 2017;45:339-46. DOI: https://doi.org/10.1177/0363546516665809

Hernigou P, Poignard A, Manicom O, Mathieu G, Rouard H. Percutaneous autologous bone marrow grafting for non-traumatic osteonecrosis of the femoral head. J Bone Joint Surg. 2002;84-B(6):891-6.

Kraeutler MJ, Chahla J, LaPrade RF, Pascual-Garrido C. Biologic options for articular cartilage wear (platelet-rich plasma, stem cells, bone marrow aspirate concentrate). Clin Sports Med. 2017;36(3):457-68. DOI: https://doi.org/10.1016/j.csm.2017.02.004

Bansal H, Leon J, Pont JL, Wilson DA, Bansal A, Agarwal D, et al. Platelet-rich plasma (PRP) in osteoarthritis (OA) knee: Correct dose critical for long term clinical efficacy. Sci Rep. 2021;11:3971. DOI: https://doi.org/10.1038/s41598-021-83025-2

Gato-Calvo L, Magalhaes J, Ruiz-Romero C, Blanco FJ, Burguera EF. Platelet-rich plasma in osteoarthritis treatment: review of current evidence. Ther Adv Chronic Dis. 2019;10:2040622319825567. DOI: https://doi.org/10.1177/2040622319825567

Pragasam SJP, Vijayalakshmi V. Metabolic Syndrome Predisposes to Osteoarthritis: Lessons from Model System. Cartilage. 2020;1947603520980161. DOI: https://doi.org/10.1177/1947603520980161

Sampath SJP, Rath SN, Kotikalapudi N, Vijayalakshmi V. Beneficial effects of secretome derived from mesenchymal stem cells with stigmasterol to negate IL-1β-induced inflammation in-vitro using rat chondrocytes-OA management. Inflammopharmacology. 2021;29(6):1701-17. DOI: https://doi.org/10.1007/s10787-021-00874-z

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 with control group. J Bone Joint Surg. 2004;86(6):1153-60. DOI: https://doi.org/10.2106/00004623-200406000-00006

Hauzeur JP, Gangji V, Appelboom T. Autologous bone marrow cell implantation in the treatment of non-traumatic osteonecrosis of the femoral head: Five-year follow-up of a prospective controlled study. Rheumatology. 2008;47(8):1083-7.

Hernigou P, Poignard A, Zilber S, Rouard H. Cell therapy of hip osteonecrosis with autologous bone marrow grafting: A 25-year follow-up of 534 hips. Clin Orthopaed Related Res. 2018;476(6):1340-8.

Kadam S, Muthyala S, Nair P, Bhonde R. Mesenchymal stem cells in diabetes and its complications: Therapeutic mechanisms and potential. World J Stem Cells. 2019;11(10):771-93.

Maxson S, Lopez EA, Yoo D, Danilkovitch-Miagkova A, LeRoux MA. Concise review: Role of mesenchymal stem cells in wound repair. Stem Cells Transl Med. 2012;1(2):142-9. DOI: https://doi.org/10.5966/sctm.2011-0018

Hungerford DS. Treatment of ischemic necrosis of the femoral head. In: Evarts CD, editor. Surg Musculoskeletal Syst. 1983;3:5029-43

Mont MA, Ragland PS, Biggins B, Friedlaender G, Patel T, Cook SD, et al. Use of bone marrow cells to improve osteonecrosis of the femoral head after core decompression. J Bone Joint Surg Am. 1996;78(6):890-902.

Gangji V, Toungouz M, Hauzeur JP. Stem cell therapy for osteonecrosis of the femoral head. Expert Opin Biol Ther. 2011;11(3): 351-61.

Zhao D, Zhang F, Wang B, Liu B, Li L, Kim SY, et al. Osteonecrosis of the femoral head: Pathogenesis and therapeutic strategies. Arthritis Res Ther. 2021;23:45.

Verma S, Saraf S, Goyal N, Nag HL, Kumar V, Arora R. Core decompression combined with bone marrow mononuclear cells and platelet-rich plasma for early stages of avascular necrosis of femoral head: A prospective study. Hip Int. 2019; 29(5): 484-91.

Cassano JM, Kennedy JG, Ross KA, Fraser EJ, Goodale MB, Fortier LA. Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):333-42. DOI: https://doi.org/10.1007/s00167-016-3981-9

Fortier LA, Barker JU, Strauss EJ, McCarrel TM, Cole BJ. The role of growth factors in cartilage repair. Clin OrthopRelat Res. 2011; 469(10):2706-15. DOI: https://doi.org/10.1007/s11999-011-1857-3

Filardo G, Kon E, Di Martino A, Di Matteo B, Merli ML, Cenacchi A, et al. Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: study design and preliminary results of a randomized controlled trial. BMC Musculoskelet Disord. 2012;13:229. DOI: https://doi.org/10.1186/1471-2474-13-229

Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: A prospective, double-blind, randomized trial. Am J Sports Med. 2013;41(2):356-64. DOI: https://doi.org/10.1177/0363546512471299