No differences in the efficacy among various core decompression
modalities and non-operative treatment: a network meta-analysis
Received: 27 February 2018 /Accepted: 4 May 2018
SICOT aisbl 2018
Background 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).
Methods 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.
Results 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.
Conclusions 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 of evidence Level I, meta-analysis.
Byung-Ho Yoon and Young-Kyun Lee equally contributed to this work
and should be considered co-first authors.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00264-018-3977-9) contains supplementary
material, which is available to authorized users.
* Ki-Choul Kim
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
Department of Orthopaedic Surgery, Dankook University College of
Medicine, Dongnam-gu, Cheonan-si, Chungcheongnam-do, South
Department of Orthopaedic Surgery, Chung-Ang University College
of Medicine, Seoul, South Korea