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Cocktail therapy for femoral head necrosis of the hip

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Cocktail therapy consists of extracorporeal shock wave treatment (ESWT), hyperbaric oxygen therapy (HBO) and alendronate. We hypothesized that this combined therapy may produce better results than ESWT alone when treating hip necrosis.

Methods

This prospective, randomized study evaluated the effectiveness of cocktail therapy in early hip necrosis, and then compared it to shock wave treatment alone. Sixty-three patients (98 hips) were randomly divided into two groups. Group A consisted of 28 patients (50 hips) who received cocktail therapy, and group B consisted of 35 patients (48 hips) who received only ESWT. Each affected hip was treated with 6,000 shocks of ESWT at 28 kV (equivalent to 0.62 mJ/mm2) in a single session. Cocktail patients also received HBO therapy performed in a multi-place chamber daily for 20 treatments, and they were administered 70 mg of alendronate orally per week for 1 year. The evaluations included clinical assessment, radiograph and MRI.

Results

After a minimum of 2-years of follow-up, the overall results showed 74% improved, 16% unchanged and 10% worsened in group A; and 79.2% improved, 10.4% unchanged and 10.4% worsened in group B (P = 0.717). Total hip replacement (THR) was performed for 10% of group A and 10.4% of group B (P = 0.946). MRI showed significant reduction in bone marrow edema and a trend of decrease in the size of the lesions in both groups, however, no difference was noted between the two groups. Cocktail therapy is effective for early hip necrosis, but the results are comparable to ESWT in short-term follow up. The joint effects of HBO and alendronate over EWST were not observed.

Conclusion

Long-term results are needed to determine whether or not the synergistic effects of ESWT, HBO and alendronate over ESWT alone exist in early hip necrosis.

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References

  1. Agarwala S, Jain D, Joshi VR, Sule A (2005) Efficacy alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study (Oxford). Rheumatology 44:352–359

    Article  CAS  PubMed  Google Scholar 

  2. Agarwala S, Sule A, Pai BU, Joshi VR (2002) Alendronate in the treatment of avascular necrosis of the hip (Oxford). Rheumatology 41:346–347

    Article  CAS  PubMed  Google Scholar 

  3. Beckmann J, Matsuura M, Grässel S, Köck F, Grifka J, Tingart M (2009) A mµCT analysis of the femoral bone stock in osteonecrosis of the femoral head compared to osteoarthrosis. Arch Orthop Trauma Surg 129:501–505

    Article  CAS  PubMed  Google Scholar 

  4. Belal MA, Reichelt A (1996) Clinical results of rotational osteotomy for treatment of avascular necrosis of the femoral head. Arch Orthop Trauma Surg 115:80–84

    Article  CAS  PubMed  Google Scholar 

  5. Black DM, Cummings SR, Karpf DB et al (1996) Randomized trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 348:1535–1541

    Article  CAS  PubMed  Google Scholar 

  6. Bone HG, Hosking D, Devogelaer JP et al (2004) Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med 350:1189–1199

    Article  CAS  PubMed  Google Scholar 

  7. Bradway JK, Morrey BF (1993) The natural history of the silent hip in bilateral atraumatic osteonecrosis. J Arthroplasty 8:383–387

    Article  CAS  PubMed  Google Scholar 

  8. Cummings SR, Black DM, Thompson DE et al (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: result from fracture intervention trial. JAMA 280:2077–2082

    Article  CAS  PubMed  Google Scholar 

  9. Desai MM, Sonone S, Bhasme V (2005) Efficacy of alendronate in the treatment of avascular necrosis of the hip (Oxford). Rheumatology 44:1331–1332

    Article  CAS  PubMed  Google Scholar 

  10. Ficat RP (1985) Idiopathic bone necrosis of the femoral head: early diagnosis and treatment. J Bone Joint Surg Br 67:3–9

    CAS  PubMed  Google Scholar 

  11. Gardeniers JWM (1993) ARCO (Association Research Circulation Osseous) international classification of osteonecrosis. ARCO Committee on Terminology and Staging. Report on the committee meeting at Santiago de Compostella. ARCO Newsl 5:79–82

    Google Scholar 

  12. Hasegawa Y, Iwata H, Torii S et al (1997) Vascularized pedicle bone grafting for non-traumatic avascular necrosis of the femoral head: a 5- to 11-year follow-up. Arch Orthop Trauma Surg 116:251–258

    Article  CAS  PubMed  Google Scholar 

  13. Hungerford DS (1990) Role of core decompression as treatment method for ischemic femur head necrosis. Orthopäde 19:219–223

    CAS  PubMed  Google Scholar 

  14. Iorio R, Healy WL, Abramowitz AJ et al (1998) Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head. J Arthroplasty 13:34–41

    Article  CAS  PubMed  Google Scholar 

  15. Ishizaka M, Sofue M, Dohmae Y et al (1997) Vascularized iliac bone graft for avascular necrosis of the femoral head. Clin Orthop 337:140–148

    Article  PubMed  Google Scholar 

  16. Kim VM, Oh HC, Kim HJ (2000) The pattern of bone marrow edema on MRI in osteonecrosis of the femoral head. J Bone Joint Surg Br 82B:837–841

    Article  Google Scholar 

  17. Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM (2005) The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am 87:2155–2159

    Article  PubMed  Google Scholar 

  18. Levin D, Norman D, Zinman C et al (1999) Treatment of experimental avascular necrosis of the femoral head with hyperbaric oxygen in rats: histological evaluation of the femoral heads during the early phrase of the reparative process. Exp Mol Pathol 67:99–108

    Article  CAS  PubMed  Google Scholar 

  19. Ludwig J, Lauber S, Lauber HJ et al (2001) High-energy shock wave treatment of femoral head necrosis in adults. Clin Orthop 387:119–126

    Article  PubMed  Google Scholar 

  20. McCormack D, Lane H, McElwain J (1996) The osteogenic potential of extracorporeal shock wave therapy: an in vivo study. Ir J Med Sci 165:20–22

    Article  CAS  PubMed  Google Scholar 

  21. Mont MA, Carbone JJ, Fairbank AC (1996) Core decompression versus non-operative management for osteonecrosis of the hip. Clin Orthop 324:169–178

    Article  PubMed  Google Scholar 

  22. Mont MA, Jones LC, Hungerford DS (2006) Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am 88:1117–1132

    Article  PubMed  Google Scholar 

  23. Reis ND, Schwartz O, Militianu D et al (2003) Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head. J Bone Joint Surg Br 85:371–375

    Article  CAS  PubMed  Google Scholar 

  24. Scully SP, Aaron RK, Urbaniak JR (1998) Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am 80:1270–1275

    CAS  PubMed  Google Scholar 

  25. Steinberg ME, Hayken GD, Steinberg DR (1995) A quantitative system for staging avascular necrosis. J Bone Joint Surg Br 77:34–41

    CAS  PubMed  Google Scholar 

  26. Vande Berg BE, Malghem JJ, Labaisse MA, Noel HM, Maldague BE (1993) MR imaging of avascular necrosis and transient marrow edema of the femoral head. Radiographics 13:501–520

    Google Scholar 

  27. Wang CJ, Huang HY, Chen HH et al (2001) Effect of shock wave therapy on acute fractures of the tibia. Clin Orthop 387:112–118

    Article  PubMed  Google Scholar 

  28. Wang CJ, Hung HY, Pai CH (2002) Shock wave-enhanced neovascularization at the tendon-bone junction: an experiment in dogs. J Foot Ankle Surg 41:16–22

    Article  CAS  PubMed  Google Scholar 

  29. Wang CJ, Wang FS, Huang CC, Yang KD, Weng LH, Huang HY (2005) Treatment of osteonecrosis of the femoral head—comparison of extracorporeal shockwave and core decompression and bone grafting. J Bone Joint Surg Am 87:2380–2387

    Article  PubMed  Google Scholar 

  30. Wang CJ, Wang FS, Yang KD, Huang CS, Hsu CC (2003) Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J Orthop Res 21:984–989

    Article  PubMed  Google Scholar 

  31. Wang CJ, Yang KD, Wang FS, Chen HS, Chen HH, Hsu CC (2004) Shock wave therapy enhances bone mass and bone strength after fracture of the femur. A study in rabbits. Bone 34:225–230

    Article  PubMed  Google Scholar 

  32. Wang CJ, Wang FS, Yang KD, Huang CC, Lee MSS, Chan YS, Wang JW, Ko JY (2008) Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate. Arch Orthop Trauma Surg 128:901–908

    Article  CAS  PubMed  Google Scholar 

  33. Wang FS, Wang CJ, Huang HC et al (2001) Physical shock wave mediates membrane hyperpolarization and Ras activation for osteogenesis in human bone marrow stromal cells. Biochem Biophys Res Commun 287:648–655

    Article  CAS  PubMed  Google Scholar 

  34. Wang FS, Wang CJ, Sheen-Chen SM et al (2002) Superoxide mediates shock wave induction of RRK-dependent osteogenic transcription factor (CBFA 1) and mesenchymal cells differentiation toward osteoprogenitors. J Biol Chem 277:10931–10937

    Article  CAS  PubMed  Google Scholar 

  35. Wang FS, Yang KD, Wang CJ et al (2002) Extracorporeal shock wave promotes bone marrow stromal cell growth and differentiation toward osteoprogenitors associated with TGF-b 1 induction. J Bone Joint Surg Br 84:457–461

    Article  CAS  PubMed  Google Scholar 

  36. Wei SY, Kliemkiewicz JJ, Lai M, Garino JP, Steinberg ME (1999) Revision total hip arthroplasty in patients with avascular necrosis. Orthopedics 22:747–757

    CAS  PubMed  Google Scholar 

  37. Yang C, Heston WDW, Gulati S, Fair WR (1988) The effect of high-energy shock waves (HESW) on human bone marrow. Urol Res 16:427–429

    Article  CAS  PubMed  Google Scholar 

  38. Zhou Q, Li Q, Yang L, Liu F (2000) Changes of blood vessels in glucocorticoid-induced avascular necrosis of the femoral head in rabbits. Chung-Hua Wai Ko Tsa Chih 38:212–215 (Chinese Journal of Surgery)

    CAS  PubMed  Google Scholar 

Download references

Acknowledgments

Fund was received in total or partial support of the research or clinical study presented in this article. The funding source was Chang Gung Research Fund (CMRPG804531). The authors thank to Mr. Adrian C. Lock and Ms Emily Davis of Atlanta, GA for the editing of this manuscript.

Conflict of interest statement

The authors declare that they did not receive any honoraria or consultancy fees for writing this manuscript. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. One author (CJW) has served as a member of the scientific advisory committee of SANUWAVE, Alpharetta, G.A., USA, and the remaining authors declared no conflict of interest.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung, 833, Taiwan

    Shan-Ling Hsu & Ching-Jen Wang

  2. Department of Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan, Kaohsiung, Taiwan

    Chung-Cheng Huang

  3. Department of Medical Research, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan, Kaohsiung, Taiwan

    Kuender D. Yang

  4. Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Taoyuan Medicine Center, Chang Gung University College of Medicine, Taiwan, Taipei, Taiwan

    Mel Shiuann-Sheng Lee & Yi-Sheng Chan

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  1. Shan-Ling Hsu
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  2. Ching-Jen Wang
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Correspondence to Ching-Jen Wang.

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Hsu, SL., Wang, CJ., Lee, M.SS. et al. Cocktail therapy for femoral head necrosis of the hip. Arch Orthop Trauma Surg 130, 23–29 (2010). https://doi.org/10.1007/s00402-009-0918-5

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  • DOI: https://doi.org/10.1007/s00402-009-0918-5

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