Lack of Conclusive Evidence of the Benefit of Biologic Augmentation in Core Decompression for Nontraumatic Osteonecrosis of the Femoral Head: A Systematic Review

Purpose: To assess whether biologic augmentation in addition to core decompression (CD), compared with CD alone, improves clinical and radiographic outcomes in the treatment of nontraumatic osteonecrosis of the femoral head (ONFH). Our hypothesis was that biologic augmentation would reduce the progression of osteonecrosis and therefore also the rate of conversion to total hip arthroplasty (THA). Methods: A systematic review was performed in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement. Six databases were searched: Central, MEDLINE, Embase, Scopus, AMED, and Web of Science. Studies comparing outcomes of CD versus CD plus biologic augmentation (with or without structural augmentation), with a reported minimum level of evidence of III and >24 months of follow-up, were eligible. Procedural success was conceptualized as (1) avoidance of conversion to THA and (2) absence of radiographic disease progression. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklists. A quantitative analysis of heterogeneity was undertaken. Results: We included studies reporting on 560 hips in 484 patients. Biologic augmentation consisted of bone marrow stem cells in 10 studies, bone morphogenic protein in 2, and platelet-rich plasma in 1. Three studies used additional structural augmentation. The median maximum follow-up time was 45 months. Only 4 studies reported improvement in all clinical scores in the augmentation group. Seven studies observed a reduction in the rate of radiographic progression, and only 5 found reduced rates of conversion to THA when using augmentation. A high risk of bias and marked heterogeneity was found, with uncertainty about the study designs implemented, analytical approaches, and quality of reporting. Conclusion: Current evidence is inconclusive regarding the benefit of biologic augmentation in CD for nontraumatic ONFH, because of inconsistent results with substantial heterogeneity and high risk of bias. Level of Evidence: III, systematic review of level I, II, and III studies.