Introduction
Methods
Eligibility criteria
Types of studies
Types of participants
Types of intervention
Types of outcome measures
Search strategy
Study selection
Data collection and analysis
Risk of bias in individual studies
Results
Study selection
Study characteristics
Year/author/region | Study design | Number of patients/hips (follow-up) | Average age (years) | Gender (M/F) | Initial AVN class (hips) | AVN etiology (patients/hips) | Follow-up time (year)/rate of lost to follow-up | Validity of the studies |
---|---|---|---|---|---|---|---|---|
2016/Chen/China [24] | Case series | 55/64 | 34.1 (22–45) | 53/5a | ARCO: I (21)/II (35)/III (8) | Alcohol abuse (58)a | 2.87 (2–4)/5.17% | M |
2014/Elmali/Turkey [25] | Case series/retrospective | 22/26 | 36 (16–48) | 14/8 | ARCO: II (11)/III (15) | Steroid use (13 patients)/alcohol abuse (2)/idiopathic (5)/pregnancy (2) | 3 (1.17–5.17)/NA | H |
2009/Chen/China [26] | Case series/retrospective | 32/33 | 37 (23–64) | 31/1 | ARCO: IIIA (26), IIIB (7) | Steroid use (1 patients)/alcohol abuse (26)/idiopathic (5) | 5.75 (0.67–13.75)/13.15% | M |
2009/Babhulkar/India [27] | Case series/retrospective | 31/31 | 32 (18–52) | 26/5 | ARCO: IIB (9)/IIIC (22) | Steroid use (12 patients)/alcohol abuse (16)/idiopathic (3) | 8/NA | M |
2009/Baksi/India [28] | Case series | 141/176 | 35.5 (16–62) | 91/61a | Ficat and Arlet: I (4)/II (75)/III (97) | Steroid use (56 hips)/alcohol abuse (7)/trauma (40)/idiopathic (83)/gout (1)a | 16.5 (10–21.5)/ 7.23% | M |
2006/Zhao/China [29] | Case series/retrospective | 197/226 | 38 (19–65) | 126/71 | Ficat and Arlet: II (91)/III (93)/IV (42) | Steroid use (53 patients)/alcohol abuse (14)/trauma (58)/idiopathic (51)/hyperlipidemia (9)/infection (11)/pregnancy (1) | 12.5 (6–19)/6.63% | M |
2004/Nagoya/Japan [30] | Case series | 29/35 | 35 (17–62) | 20/9 | ARCO: II (28)/III (7) JIC classification: C1 (17), C2 (18) | Steroid use (14 patients)/alcohol abuse (10)/idiopathic (5) | 8.58 (3–17)/NA | H |
2001/Eisenschenk/Germany [31] | Case series | 82/82 | NA | 81/21 a | ARCO: I-II (62)/III (1)/IV (19) | Steroid use (12 patients)/alcohol abuse (20)/trauma (22)/diabetes (6)/hyperlipidemia (10)/sickle cell disease (1)/unknown (11) | 5 (0.5–10)/19.61%b | VH |
1997/Hasegawa/Japan [33] | Case series | 26/31 | 38.3 (25–53) | 23/3 | Inoue and Ono classification: II (28)/IIIA (3) JIC classification: IB (25)/IC (4)/II (4)/ IIIB (1) | Steroid use (6 patients)/alcohol abuse (15)/idiopathic (5) | 8 (5–11)/100% | M |
1997/Ishizaka/Japan [32] | Case series | 24/31 | 33 (15–66) | 16/81 | Ficat and Arlet: II (18)/III (13) | Steroid use (17 hips)/alcohol abuse (10)/idiopathic (4) | 6 (2–11)/22.58% patient | H |
1996/Leung/China [35] | Case series | 18/21 | 32 (24–52) | 12/6 | Myer’s classification: III (6)/IV (8)/V (7) | Steroid use (7 hips)/alcohol abuse (3)/trauma (3)/idiopathic (8) | NA (2–11)/NA | H |
1996/Wassenaar/Netherlands [34] | Case series | 9/12 | 37.5 (14–54) | 5/4 | Ficat and Arlet: II (5)/III (7) | Steroid use (3 patients)/alcohol abuse (1)/trauma (3)/chemotherapy (1)/sickle cell disease (1) | 4.17/30.77% | VH |
1993/Iwata/Japan [36] | Case series | 19/23 | 39 (25–53) | 17/2 | JIC stage: II (20), III (3) JIC classification: I-C (19)/II (2)/III-B (1) | Steroid use (3 patients)/alcohol abuse (13)/idiopathic (3) | 2.91 (1–6)/100% | H |
Year/author | Study design | Number of patients/hips (follow-up) | Average age (years) | Gender (M/F) | Initial AVN class (hips) | AVN etiology (patients/hips) | Follow-up time (years) /rate | Validity of the studies | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
TIG | Other | TIG | Other | TIG | Other | TIG | Other | TIG | Other | TIG | Other | |||
2016/Zhao/Chinaa [21] | RCT | 23/23 | 25/25 | 30 ± 7 | 33 ± 8 | 14/9 | 15/10 | ARCO: IIA (4)/IIB (5)/IIC (4)/IIIA (4)/IIIB (4)/IIIC (2) | ARCO: IIA (5)/IIB (5)/IIC (3) IIIA (5)/IIIB (4)/IIIC (3) | Steroid (7 patients)/alcohol (7)/others (9) | Steroid (9 patients)/alcohol (5)/others (11) | 1/100% | 1/100% | Additional file 1: Appendix 2 |
2006/Yen/Chinab [22] | Case-control | 33/39 | 22/22 | 40 (26–63) | 38 (28–52) | 30/3 | 20/2 | Steinberg: II (11)/III (12)/IV (16) | Steinberg: II (4)/III (11)/IV (7) | Steroid (1 patient)/alcohol (15)/idiopathic (17) | Steroid (1 patient)/alcohol (12)/idiopathic (9) | > 4/NA | > 3/NA | Additional file 1: Appendix 2 |
2003/Hasegawa/Japan+c [23] | Case-control | 26/31 | 63/77 | 37.9 (25–53) | 39 (19–64) | 23/3 | 44/19 | Ficat and Arlet: II (28)/III (3) JIC classification: IB (1)/IC (25)/II (4)/III (1) | Ficat and Arlet: II (34)/III (43) JIC classification: IB (3)/IC (62)/II (12) | Steroid (8 hips)/alcohol (16)/idiopathic (7) | Steroid (46 hips)/alcohol (24)/idiopathic (7) | 13 (10–15)/3.84% | 7 (5–11)/3.07% | Additional file 1: Appendix 2 |
Year/author | Indications/contraindication | Kinds of pedicle bone flap | Size of bone flap (cm) | Duration of the operation (minutes) | Postoperative management | Additional note |
---|---|---|---|---|---|---|
2016/Chen [24] | NA | Sartorius muscle-pedicle bone flap | 4 × 2 × 2.5 | 65 (45–90) | Partial weight-bearing walking at 8 to 12 weeks, and further advice was subject to radiographic evidence after 3 to 6 months of operation | Bone flap was fixed by absorbable screw |
2014/Elmali [25] | NA | Deep circumflex iliac artery pedicle bone flap | 6 × 2 × 2 | 210 (168–258) | The hip was positioned in 20° flexion for 3 weeks, full weight-bearing walking at 6 months | – |
2009/Babhulkar [28] | NA | Deep circumflex iliac artery pedicle bone flap | NA | NA | The limb was kept in 20° abduction and 30° flexion and 10° of internal rotation, and allowed free movements in bed after 15 days, non-weight-bearing after 4–6 weeks, partial weight-bearing after 10 weeks and full weight-bearing after 14–16 weeks | – |
2009/Chen [26] | NA | Deep circumflex iliac artery pedicle bone flap | 5 × 1.5 | NA | Toe-touch weight-bearing for 6 weeks, then partial weight-bearing for 6 months and full weight-bearing was allowed after 6 months | – |
2009/Baksi [27] | Pain and discomfort around the hip, limitation of movement | Tensor fascia lata muscle-pedicle bone flap | 2.5 × 2.5 | NA | Partial weight-bearing was allowed after 5 weeks, and full weight-bearing was allowed after 4–5 months | Bone flap was fixed by Vicryl thread |
2006/Zhao [29] | NA | Ascending branch of the lateral femoral circumflex artery pedicle bone flap | 5 × 3 | 90 (55–120) | Bed rest with traction was used for 45 days postoperatively, progressive weight-bearing was permitted after the graft incorporated with the host area. Full weight-bearing was achieved by 6 months | – |
2004/Nagoya [30] | NA | Deep circumflex iliac artery pedicle bone flap | NA | NA | Bed rest was prescribed for 2 weeks. Weight-bearing exercise started 4 weeks after surgery, followed by partial weight-bearing for the next 6 months | Bone flap was fixed by AO screw |
2001/Eisenschenk [31] | NA | Deep circumflex iliac artery pedicle bone flap | 6 × 2 | NA | The hip was positioned in 20° after operation, weight-bearing was not allowed for 6 months after operation | – |
1997/Hasegawa [33] | Indications: Collapse < 2 mm JIC IC, II type | Superficial circumflex iliac artery pedicle bone flap (deep circumflex iliac artery was used in 8 hips) | 5 × 1.5 | NA | Ambulation was not permitted for 3 weeks, partial weight-bearing was encouraged after 12 weeks, full weight-bearing was permitted after 24 weeks. | Hyperbaric oxygen therapy was conducted on 11 patients |
1997/Ishizaka [32] | NA | Deep circumflex iliac artery pedicle bone flap | 5 × 2 × 2 | 150 | Patients were kept non-weight-bearing for 6 months, followed by partial weight-bearing with for the next 6 months. | – |
1996/Leung [35] | NA | Deep circumflex iliac artery pedicle bone flap | NA | NA | The hip was kept in 30″ flexion and neutral rotation for 1 week. Hip motion was encouraged. Bed rest was continued for 3 to 4 weeks. Non-weight-bearing walking was allowed• after 4 weeks, and weight-bearing was delayed until 8 weeks | – |
1996/Wassenaar [34] | NA | NA | NA | NA | NA | – |
1993/Iwata [36] | Indications: JIC I/II stage Contraindication: collapse > 5 mm | Superficial circumflex iliac artery pedicle bone flap (deep circumflex iliac artery was additionally used in 2 cases) | NA | NA | Active exercise in the second week, exercise in the pool in the fourth week, one-third weight-bearing in the 12th week, and full weight-bearing in the 24th week | Hyperbaric oxygen therapy was conducted on 13 patients |
Year/author | Indications/contraindication | Kinds of pedicle bone flap | Size of bone flap (cm) | Duration of the operation (minutes) | Postoperative management | Additional note | |||||
---|---|---|---|---|---|---|---|---|---|---|---|
TIG | Other | TIG | Other | TIG | Other | TIG | Other | TIG | Other | ||
2016/Zhaoa [21] | NA | Ascending branch of the lateral femoral circumflex artery pedicle bone flap | 5 × 3 | 5 × 3 | NA | NA | NA | NA | Bone flap was fixed by absorbable screw | – | |
2006/Yenb [22] | Steinberg II, III, IV Stage | NA | NA | NA | NA | 210 | 420 | NA | NA | – | – |
2003/Hasegawac [23] | TIG: Ficat II stage and JIC IC or II type Other: Ficat III stage or above, and JIC IC or II type, and the necrosis area < 36% in frog lateral view | Superficial circumflex iliac artery pedicle bone flap | – | NA | – | NA | NA | Exercises were started in the third week after the operation. At 12 weeks partial weight-bearing (10 kg) and at 24 weeks full weight-bearing were allowed. | – | – |
Outcome
Year/author | Clinical evaluation | Clinical evaluation based on the Ficat stage classification (mean difference/clinical success rate) | Radiographic evaluation (radiographic failure rate) | Complications/rate of complications | ||||
---|---|---|---|---|---|---|---|---|
Mean differencea (scale used) | Clinical success rateb | I | II | III | IV | |||
2016/Chen [24] | 31.06 (HHS) | 79.68% | 32.22/90.47% | 31.2/77.14% | 26.13/62.50% | – | NA | NA |
2014/Elmali [25] | 30.8 (HHS) | 69.23% | – | NA | NA | – | 34.62% II (36.36%) III (33.33%) | 2 patients suffering from obesity with serious drainage for 1 week 2/22 (9.09%) |
2009/Babhulkar [28] | 28.19 (HHS) | 58.06% | – | 29.88/62.50% | 27.61/56.5% | – | 6.45% | Superficial infection at the operative site (1 patient) 3.22% |
2009/Chen [26] | 8.92 (HHS) | NA | – | – | NA | – | 100% | NA |
2009/Baksi [27] | 4.06 (HSS) | 85.79% | 1/100% | 4.8/92% | 3.6/80.4% | – | 9.65% | Superficial wound infection (9 hips), terminal limitation of hip movements (20), persistence of painless limp (16) 25.57% |
2006/Zhao [29] | 38 (HHS) | 86.28% | – | NA/96% | NA/90% | NA/57% | 28.76% | Deep venous thromboses (4 patients), meralgia paresthetica (3), secondary wound healing (9) 8.12% |
2004/Nagoya [30] | 17.35 (JOA) | NA | – | NA | NA | – | NA | Damage of cutaneus femoris lateralis nerve (10 patients) 34.48% |
2001/Eisenschenk [31] | NA (HHS) | 86.6% | NA | NA | NA | – | 48.89% | Deep thrombosis of the femoral vein (2 patients), damage of cutaneus femoris lateralis nerve (7), abdominal weakness without evidence of hernia (5), secondary wound healing (2) 16/82 (19.51%) |
1997/Hasegawa [33] | 21 (HHS) | 63.33% | – | NA | NA | – | NA | Secondary wound healing (3 hips), damage of cutaneus femoris lateralis nerve (8) 36.67% |
1997/Ishizaka [32] | 2.2 (Merle d’Aubigne and Postel score) | 77% | – | NA | NA | – | 48.38% | NA |
1996/Leung [35] | 5.06 (Charnley hip scoring system) | 77.78% | – | – | NA | – | NA | NA |
1996/Wassenaar [34] | 28 (HHS) | NA | NA | NA | NA | – | 41.66% | NA |
1993/Iwata [36] | 9.7 (JOA) | NA | NA | 12.46/NA | 3.34/NA | – | 34.78% | Secondary wound healing (2 hips), damage of cutaneus femoris lateralis nerve (5) 30.43% |
Year/author | Clinical evaluation | Clinical evaluation based on the Ficat stage classification (mean difference/clinical success rate) | Radiographic evaluation (radiographic failure) | Complications /rate of complications | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Mean difference (scale used) | Clinical success rate | TIG | Other | TIG | Other | TIG | Other | |||||||||
TIG | Other | TIG | Other | I | II | III | IV | I | II | III | IV | |||||
2016/Zhaoa [21] | 26.08 (HHS) | 22.53 (HHS) | 95.65% | 76.00% | – | 21.16/100% | 32.37/90% | – | – | 17.34/92.31% | 28.07/58.33% | – | 8.7% | 24% | NA | NA |
2006/Yenb[22] | 2 (Charnley Functional Hip Score) | 3 (Charnley Functional Hip Score) | NA | NA | – | NA | NA | NA | – | NA | NA | NA | 43.59% | 18.18% | Mild wound-edge necrosis (2), damage of cutaneus femoris lateralis nerve (5), inguinal protrusion (1) 24.24% | Claw toe (1) 4.54% |
2003/Hasegawa c [23] | 14 (HHS) | 18 (HHS) | 58% | 68% | – | NA | NA | – | – | NA | NA | – | NA | NA | Mild wound-edge necrosis (3), damage of cutaneus femoris lateralis nerve (8) 42.31% | Early deep infection (1), trochanteric fracture (5), pseudarthrosis (1) 11.11% |
Study | Rate of convention to arthroplasty (arthroplasty/total hips) | Method of report in original studies | Survival rate (based on the definition in original studies) | Definition of hip-preservation failure in individual study | Survival rate based on stage |
---|---|---|---|---|---|
2016/Zhaoa [21] | 0% | NA | NA | NA | NA |
2016/Chen [24] | 14.06% (9/64) | Survival curve | 81.25% | The collapse of the femoral head was larger than 4 mm, with significant osteoarthritis; or hip replacement | NA |
2014/Elmali [25] | 19.23% (5/26) | Reported cases of arthroplasty | NA | NA | NA |
2009/Chen [26] | 75.76% (25/33) | Survival curve | 24.24% | Conversion to replacement arthroplasty | ARCO IIIB, 0% ARCO IIIA, 30.77% |
2009/Babhulkar [28] | 3.23% (1/31) | Reported cases of arthroplasty | NA | NA | NA |
2009/Baksi [27] | Fail to recalculate | Survival curve | 83.97% | Radiological deterioration, resulting in the reduction of the clinical HSS score to below 20, requiring subsequent operative intervention | Ficat II, 91% Ficat III, 82% |
2006/Yenb [22] | 10.26% (4/39) | Reported cases of arthroplasty | 10.26% | Conversion to replacement arthroplasty | Steinberg III, 75% Steinberg IV, 93.75% |
2006/Zhao [29] | 6.19% (14/226) | Reported cases of arthroplasty | 93.81% | Conversion to replacement arthroplasty | NA |
2004/Nagoya [30] | NA | NA | NA | NA | NA |
2003/Hasegawab [23] | 6.45% (2/31) | Survival curve | 5Y, 85% 10Y, 67% | The development of symptoms requiring arthroplasty or a Harris hip score of less than 70 points as the endpoint | NA |
2001/Eisenschenk [31] | 8.89% (8/90) | Reported cases of arthroplasty | NA | NA | NA |
1997/Hasegawa [33] | 3.23% (1/31) | Survival curve | Satuation 1: 3Y, 70%; 5Y, 60% satuation 2: 3Y, 60%; 5Y, 50% | Satuation 1: overall clinical score of less than 70 points or conversion to an endoprosthesis satuation 2: radiographic stage further than stage III-B (collapse by more than 5 mm) | NA |
1997/Ishizaka [32] | 9.68% (3/31) | Reported cases of arthroplasty | NA | NA | NA |
1996/Leung [35] | 4.76% (1/21) | Reported cases of arthroplasty | NA | NA | NA |
1996/Wassenaar [34] | 8.33% (1/12) | Reported cases of arthroplasty | NA | NA | NA |
1993/Iwata [36] | 4.35% (1/23) | Reported cases of arthroplasty | NA | NA | NA |