Bayesian Network Meta-Analysis of the Effectiveness of Various Interventions for Nontraumatic Osteonecrosis of the Femoral Head

OBJECTIVE: To assess the effectiveness of various therapeutic hip preservation strategies on patients with nontraumatic osteonecrosis of the femoral head (ONFH). DESIGN: This is a systematic review of previous literature and in-depth Bayesian network meta-analysis of randomized controlled trials (RCTs) to compare the clinical effect of various operation methods and one physical intervention (extracorporeal shockwave). DATA SOURCES: Electronic literature, for studies published up to December 2017, was collected from PubMed, Medline, and the Cochrane Library. STUDY SELECTION: We selected RCTs on patients with ONFH. Treatment methods included extracorporeal shockwave (ESW), core decompression (CD), multiple drilling decompression (DD), vascularized fibular grafting (VFG), free-vascularized fibular grafting (FVFG), inverted femoral head grafting (IFHG), vascular iliac pedicle bone grafting (VIPBG), osteotomy, and tantalum implantation (TI). OUTCOME: The primary outcome was Harris score; the secondary outcome was Harris hip score (HHS), including total hip arthroplasty requirement (THA) and progression to collapse. RESULTS: A total of 14 randomized controlled trials were investigated. ESW had the highest improvement on Harris score (probability best 52%), followed by VFG (probability was 38%). In the meanwhile, VFG also proved to be superior in reducing the failure rates of treatment (probability lowest 59%), followed by ESW (probability lowest 24%). In femoral necrosis stage-II, VFG achieved the highest probability in preventing treatment failures (52%) and showed better performance in reducing treatment failure rates than CD. CONCLUSION: ESW therapy (ESWT) is the most effective intervention to improve HHS, and VFG shows superior effect on reducing treatment failure rates.