Preservation of necrotic bone structures: an alternative to osteonecrosis of femoral head replacement therapy_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MA Jinhui ^1,2 , SUN Wei ³ ,  PENG Jiang ⁴ ,  CHENG Liming ¹

1. Department of Orthopedic and Joint Surgery, China-Japan Friendship Hospital, Beijing, 100029, P. R. China;
2. Peking University China-Japan Friendship Clinical Medical College, Beijing, 100029, P. R. China;
3. Department of Orthopedic and Joint Surgery, Chengdu Hip Preservation Hospital of Femoral Head Orthopedics, Chengdu Sichuan, 610036, P. R. China;
4. Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100853, P. R. China;

Corresponding?author：

PENG Jiang, Email: pengjiang301@126.com; CHENG Liming, Email: drchengliming@126.com

Keywords：

Osteonecrosis of the femoral head; progression mechanism; substitute therapy; bone marrow flushing treatment; destructive inflammatory response

DOI：

10.7507/1002-1892.202604061

Video：

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Abstract Full text Figures/Tables Video References Cited by

Hip preservation treatment is the first choice for young and middle-aged patients with osteonecrosis of the femoral head (ONFH). Currently, there is considerable uncertainty in treatment outcomes, which is the dilemma faced in treating ONFH and is the main reason why young and middle-aged people undergo hip replacement. The history of hip-preserving treatment for ONFH revolves around the “substitute therapy” approach of replacing necrotic bone with various materials. As understanding of the mechanisms of bone necrosis progression deepens, the fundamental goal of hip-preserving treatment has become to protect the necrotic bone structure from destruction. In other words, the goal is to halt the progression of bone necrosis and provide sufficient time and space for creeping replacement of the necrotic bone. The core treatment method is to use minimally invasive techniques to perform bone marrow flushing on the necrotic bone. While maintaining the stability of the bone necrosis microenvironment, stem cells and organoids are used to fill the bone tissue gaps vacated by the bone marrow flushing, promoting repair of the necrotic bone and maintaining a positive balance between bone repair and bone destruction.

Citation： MA Jinhui, SUN Wei, PENG Jiang, CHENG Liming. Preservation of necrotic bone structures: an alternative to osteonecrosis of femoral head replacement therapy. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(5): 689-694. doi: 10.7507/1002-1892.202604061 Copy

1.	Charcot JM. Clinical lectures on senile and chronic diseases. London: The New Sydenham Society, 1881: 132-138.
2.	Phemister DB. Repair of bone in the presence of aseptic necrosis resulting from fractures, transplantations, and vascular obstruction. J Bone Joint Surg (Am), 1930, 12: 769-787.
3.	Axhausen G. über einfache, aseptische Knochen- und Knorpelnekrose, Chondritis dissecans und Arthritis deformans. Arch Klin Chir, 1912, 99: 519-574.
4.	Axhausen G. Knochennekrose und sequesterbildung. Dtsch Med Wochenschr, 1914, 40(3): 111-115.
5.	Compere EL. Avascular necrosis of large segmental fracture fragments of the long bones. J Bone Joint Surg (Am), 1949, 31A(1): 47-54.
6.	Hungerford DS. Bone marrow pressure, venography, and core decompression in ischemic necrosis of the femoral head//The Hip: Proceedings of the Hip Society. St. Louis: C.V. Mosby, 1979: 245-254.
7.	Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg (Br), 1985, 67(1): 3-9.
8.	Phemister DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg (Am), 1949, 31(1): 55-66.
9.	Cui Q, Saleh KJ. Surgical and molecular advances in osteonecrosis: editorial comment. Clin Orthop Relat Res, 2008, 466(5): 1017-1019.
10.	Totty WG, Murphy WA, Ganz WI, et al. Magnetic resonance imaging of the normal and ischemic femoral head. AJR Am J Roentgenol, 1984, 143(6): 1273-1280.
11.	Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). New England Journal of Medicine, 1992, 326(22): 1473-1479.
12.	Canale ST, Beaty JH. Campbell’s operative orthopaedics. 12th ed. Philadelphia: Elsevier Mosby, 2013: 2846-2848.
13.	Koo KH, Mont MA, Jones LC. Osteonecrosis. Berlin Heidelberg: Springer-Verlag, 2014: 1-532.
14.	中國醫師協會骨科醫師分會骨循環與骨壞死專業委員會, 中華醫學會骨科分會骨顯微修復學組, 國際骨循環學會中國區. 中國成人股骨頭壞死臨床診療指南(2020). 中華骨科雜志, 2020, 40(20): 1365-1376.
15.	陶海榮, 張長青, 曾炳芳, 等. 磷酸三鈣結合富血小板血漿修復股骨頭壞死的研究. 中國修復重建外科雜志, 2005, 19(3): 170-173.
16.	Deie M, Ochi M, Adachi N, et al. Artificial bone grafting [calcium hydroxyapatite ceramic with an interconnected porous structure (IP-CHA)] and core decompression for spontaneous osteonecrosis of the femoral condyle in the knee. Knee Surg Sports Traumatol Arthrosc, 2008, 16(8): 753-758.
17.	Kawate K, Yajima H, Ohgushi H, et al. Tissue-engineered approach for the treatment of steroid-induced osteonecrosis of the femoral head: transplantation of autologous mesenchymal stem cells cultured with beta-tricalcium phosphate ceramics and free vascularized fibula. Artif Organs, 2006, 30(12): 960-962.
18.	Gangji V, De Maertelaer V, Hauzeur JP. Autologous bone marrow cell implantation in the treatment of non-traumatic osteonecrosis of the femoral head: Five year follow-up of a prospective controlled study. Bone, 2011, 49(5): 1005-1009.
19.	Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res, 2002, (405): 14-23.
20.	Zhang Y, Zhang L, Sun R, et al. A new 3D printed titanium metal trabecular bone reconstruction system for early osteonecrosis of the femoral head. Medicine (Baltimore), 2018, 97(26): e11088. doi: 10.1097/MD.0000000000011088.
21.	Phemister DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg (Am), 1949, 31A(1): 55-66.
22.	何偉, 李勇, 張慶文, 等. 自體或同種異體腓骨聯合打壓植骨治療股骨頭壞死的初步研究. 中國修復重建外科雜志, 2009, 23(5): 530-533.
23.	Rosenwasser MP, Garino JP, Kiernan HA, et al. Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis. Clin Orthop Relat Res, 1994, (306): 17-27.
24.	李子榮. 經股骨頭頸開窗病灶清除壓緊植骨治療早中期股骨頭壞死//中華醫學會第八屆骨科學術會議暨第一屆國際COA學術大會論文摘要集. 北京: 中華醫學會, 2006.
25.	Urbaniak JR, Coogan PG, Gunneson EB, et al. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg (Am), 1995, 77(5): 681-94.
26.	毛履真, 王坤正, 劉安慶. 吻合血管腓骨移植治療股骨頭缺血性壞死. 中華顯微外科雜志, 1989, 12(1): 20-23.
27.	王坤正, 毛履真, 賀西京, 等. 吻合血管腓骨移植治療股骨頭缺血性壞死220例. 中華顯微外科雜志, 1993, 16(2): 101-103.
28.	張長青. 改良的吻合血管游離腓骨移植治療股骨頭缺血性壞死//中國康復醫學會修復重建外科專業委員會第十四次全國學術交流會論文集. 重慶: 第三軍醫大學西南醫院, 2004: 153-156.
29.	向富州, 殷文靖, 朱振中, 等. 帶血管腓骨移植治療股骨頭壞死后股骨頭塌陷的危險因素. 中華關節外科雜志(電子版), 2018, 12(5): 626-630.
30.	Arlet J, Ficat P, Lartigue G, et al. Clinical research on intraosseous pressure in the upper femoral metaphysis and epiphysis in humans. Application to the diagnosis of ischemia and necrosis. Rev Rhum Mal Osteoartic, 1972, 39(11): 717-723.
31.	童培建, 肖魯偉, 許茂盛, 等. 股骨頭壞死及融通術后數字減影血管造影的初步觀察. 骨與關節損傷雜志, 2000, 15(5): 323-235.
32.	王榮田, 李?, 李泰賢, 等. 中藥動脈灌注治療非創傷性股骨頭壞死患者近期療效觀察. 介入放射學雜志, 2021, 30(2): 158-163.
33.	Mont MA, Salem HS, Piuzzi NS, et al. Nontraumatic osteonecrosis of the femoral head: where do we stand today? A 5-year update. J Bone Joint Surg (Am), 2020, 102(12): 1084-1099.
34.	Adapala NS, Yamaguchi R, Phipps M, et al. Necrotic bone stimulates proinflammatory responses in macrophages through the activation of Toll-like receptor 4. Am J Pathol, 2016, 186(11): 2987-2999.
35.	Koo KH, Ahn IO, Kim R, et al. Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images. Radiology, 1999, 213(3): 715-722.
36.	Kubo T, Yamamoto T, Inoue S, et al. Histological findings of bone marrow edema pattern on MRI in osteonecrosis of the femoral head. J Orthop Sci, 2000, 5(5): 520-523.
37.	Kokubo T, Takatori Y, Ninomiya S, et al. Fat intensity within the hypointense zone on MR imaging of avascular necrosis of the femoral head. J Comput Assist Tomogr, 1991, 15(3): 470-473.
38.	Monte FA, Park MS, Gokani V, et al. Development of a novel minimally invasive technique to washout necrotic bone marrow content from epiphyseal bone: A preliminary cadaveric bone study. Orthop Traumatol Surg Res, 2020, 106(4): 709-715.
39.	馬金輝, 李宏旭, 劉浩洋, 等. 雙通道髓芯減壓聯合髓腔沖洗技術治療非創傷性股骨頭壞死. 中國修復重建外科雜志, 2025, 39(4): 399-405.
40.	Arlet J, Ficat P, Sebbag D, et al. The use of measurement of intramedullary pressure in the greater trochanter in man, particularly in the diagnosis of osteonecrosis of the femoral head. Rev Rhum Mal Osteoartic, 1968, 35(5): 250-256.
41.	Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res, 1978, (130): 191-201.
42.	張啟棟, 李彤, 王衛國, 等. 股骨頭壞死部分股骨頭置換術. 中國矯形外科雜志, 2025, 33(14): 1321-1325, 1331.
43.	林禧龍, 王玉, 彭江, 等. 類器官芯片在異種器官移植中的應用前景. 器官移植, 2025, 16(4): 502-508.
44.	Wu J, He Y, Qian T, et al. Stromal vascular fraction self-assembles vascularized osteogenic organoids with immunomodulatory functions. Bioact Mater, 2025, 57: 323-343.
45.	Zhang L, Zhang Y, Wan Z, et al. Piezo1 mediated scaffold-free rapid generation of self-mineralized bone organoids via activating Wnt signaling. Mater Today Bio, 2025, 36: 102620. doi: 10.1016/j.mtbio.2025.102620.
46.	Dalle Carbonare L, Minoia A, Braggio M, et al. Extracellular vesicles in osteogenesis: comparative analysis of stem cell sources, conditioning strategies, and in vitro models toward advanced bone regeneration. Cells, 2025, 15(1): 27. doi: 10.3390/cells15010027.

1. Charcot JM. Clinical lectures on senile and chronic diseases. London: The New Sydenham Society, 1881: 132-138.
2. Phemister DB. Repair of bone in the presence of aseptic necrosis resulting from fractures, transplantations, and vascular obstruction. J Bone Joint Surg (Am), 1930, 12: 769-787.
3. Axhausen G. über einfache, aseptische Knochen- und Knorpelnekrose, Chondritis dissecans und Arthritis deformans. Arch Klin Chir, 1912, 99: 519-574.
4. Axhausen G. Knochennekrose und sequesterbildung. Dtsch Med Wochenschr, 1914, 40(3): 111-115.
5. Compere EL. Avascular necrosis of large segmental fracture fragments of the long bones. J Bone Joint Surg (Am), 1949, 31A(1): 47-54.
6. Hungerford DS. Bone marrow pressure, venography, and core decompression in ischemic necrosis of the femoral head//The Hip: Proceedings of the Hip Society. St. Louis: C.V. Mosby, 1979: 245-254.
7. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg (Br), 1985, 67(1): 3-9.
8. Phemister DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg (Am), 1949, 31(1): 55-66.
9. Cui Q, Saleh KJ. Surgical and molecular advances in osteonecrosis: editorial comment. Clin Orthop Relat Res, 2008, 466(5): 1017-1019.
10. Totty WG, Murphy WA, Ganz WI, et al. Magnetic resonance imaging of the normal and ischemic femoral head. AJR Am J Roentgenol, 1984, 143(6): 1273-1280.
11. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). New England Journal of Medicine, 1992, 326(22): 1473-1479.
12. Canale ST, Beaty JH. Campbell’s operative orthopaedics. 12th ed. Philadelphia: Elsevier Mosby, 2013: 2846-2848.
13. Koo KH, Mont MA, Jones LC. Osteonecrosis. Berlin Heidelberg: Springer-Verlag, 2014: 1-532.
14. 中國醫師協會骨科醫師分會骨循環與骨壞死專業委員會, 中華醫學會骨科分會骨顯微修復學組, 國際骨循環學會中國區. 中國成人股骨頭壞死臨床診療指南(2020). 中華骨科雜志, 2020, 40(20): 1365-1376.
15. 陶海榮, 張長青, 曾炳芳, 等. 磷酸三鈣結合富血小板血漿修復股骨頭壞死的研究. 中國修復重建外科雜志, 2005, 19(3): 170-173.
16. Deie M, Ochi M, Adachi N, et al. Artificial bone grafting [calcium hydroxyapatite ceramic with an interconnected porous structure (IP-CHA)] and core decompression for spontaneous osteonecrosis of the femoral condyle in the knee. Knee Surg Sports Traumatol Arthrosc, 2008, 16(8): 753-758.
17. Kawate K, Yajima H, Ohgushi H, et al. Tissue-engineered approach for the treatment of steroid-induced osteonecrosis of the femoral head: transplantation of autologous mesenchymal stem cells cultured with beta-tricalcium phosphate ceramics and free vascularized fibula. Artif Organs, 2006, 30(12): 960-962.
18. Gangji V, De Maertelaer V, Hauzeur JP. Autologous bone marrow cell implantation in the treatment of non-traumatic osteonecrosis of the femoral head: Five year follow-up of a prospective controlled study. Bone, 2011, 49(5): 1005-1009.
19. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res, 2002, (405): 14-23.
20. Zhang Y, Zhang L, Sun R, et al. A new 3D printed titanium metal trabecular bone reconstruction system for early osteonecrosis of the femoral head. Medicine (Baltimore), 2018, 97(26): e11088. doi: 10.1097/MD.0000000000011088.
21. Phemister DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg (Am), 1949, 31A(1): 55-66.
22. 何偉, 李勇, 張慶文, 等. 自體或同種異體腓骨聯合打壓植骨治療股骨頭壞死的初步研究. 中國修復重建外科雜志, 2009, 23(5): 530-533.
23. Rosenwasser MP, Garino JP, Kiernan HA, et al. Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis. Clin Orthop Relat Res, 1994, (306): 17-27.
24. 李子榮. 經股骨頭頸開窗病灶清除壓緊植骨治療早中期股骨頭壞死//中華醫學會第八屆骨科學術會議暨第一屆國際COA學術大會論文摘要集. 北京: 中華醫學會, 2006.
25. Urbaniak JR, Coogan PG, Gunneson EB, et al. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg (Am), 1995, 77(5): 681-94.
26. 毛履真, 王坤正, 劉安慶. 吻合血管腓骨移植治療股骨頭缺血性壞死. 中華顯微外科雜志, 1989, 12(1): 20-23.
27. 王坤正, 毛履真, 賀西京, 等. 吻合血管腓骨移植治療股骨頭缺血性壞死220例. 中華顯微外科雜志, 1993, 16(2): 101-103.
28. 張長青. 改良的吻合血管游離腓骨移植治療股骨頭缺血性壞死//中國康復醫學會修復重建外科專業委員會第十四次全國學術交流會論文集. 重慶: 第三軍醫大學西南醫院, 2004: 153-156.
29. 向富州, 殷文靖, 朱振中, 等. 帶血管腓骨移植治療股骨頭壞死后股骨頭塌陷的危險因素. 中華關節外科雜志(電子版), 2018, 12(5): 626-630.
30. Arlet J, Ficat P, Lartigue G, et al. Clinical research on intraosseous pressure in the upper femoral metaphysis and epiphysis in humans. Application to the diagnosis of ischemia and necrosis. Rev Rhum Mal Osteoartic, 1972, 39(11): 717-723.
31. 童培建, 肖魯偉, 許茂盛, 等. 股骨頭壞死及融通術后數字減影血管造影的初步觀察. 骨與關節損傷雜志, 2000, 15(5): 323-235.
32. 王榮田, 李?, 李泰賢, 等. 中藥動脈灌注治療非創傷性股骨頭壞死患者近期療效觀察. 介入放射學雜志, 2021, 30(2): 158-163.
33. Mont MA, Salem HS, Piuzzi NS, et al. Nontraumatic osteonecrosis of the femoral head: where do we stand today? A 5-year update. J Bone Joint Surg (Am), 2020, 102(12): 1084-1099.
34. Adapala NS, Yamaguchi R, Phipps M, et al. Necrotic bone stimulates proinflammatory responses in macrophages through the activation of Toll-like receptor 4. Am J Pathol, 2016, 186(11): 2987-2999.
35. Koo KH, Ahn IO, Kim R, et al. Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images. Radiology, 1999, 213(3): 715-722.
36. Kubo T, Yamamoto T, Inoue S, et al. Histological findings of bone marrow edema pattern on MRI in osteonecrosis of the femoral head. J Orthop Sci, 2000, 5(5): 520-523.
37. Kokubo T, Takatori Y, Ninomiya S, et al. Fat intensity within the hypointense zone on MR imaging of avascular necrosis of the femoral head. J Comput Assist Tomogr, 1991, 15(3): 470-473.
38. Monte FA, Park MS, Gokani V, et al. Development of a novel minimally invasive technique to washout necrotic bone marrow content from epiphyseal bone: A preliminary cadaveric bone study. Orthop Traumatol Surg Res, 2020, 106(4): 709-715.
39. 馬金輝, 李宏旭, 劉浩洋, 等. 雙通道髓芯減壓聯合髓腔沖洗技術治療非創傷性股骨頭壞死. 中國修復重建外科雜志, 2025, 39(4): 399-405.
40. Arlet J, Ficat P, Sebbag D, et al. The use of measurement of intramedullary pressure in the greater trochanter in man, particularly in the diagnosis of osteonecrosis of the femoral head. Rev Rhum Mal Osteoartic, 1968, 35(5): 250-256.
41. Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res, 1978, (130): 191-201.
42. 張啟棟, 李彤, 王衛國, 等. 股骨頭壞死部分股骨頭置換術. 中國矯形外科雜志, 2025, 33(14): 1321-1325, 1331.
43. 林禧龍, 王玉, 彭江, 等. 類器官芯片在異種器官移植中的應用前景. 器官移植, 2025, 16(4): 502-508.
44. Wu J, He Y, Qian T, et al. Stromal vascular fraction self-assembles vascularized osteogenic organoids with immunomodulatory functions. Bioact Mater, 2025, 57: 323-343.
45. Zhang L, Zhang Y, Wan Z, et al. Piezo1 mediated scaffold-free rapid generation of self-mineralized bone organoids via activating Wnt signaling. Mater Today Bio, 2025, 36: 102620. doi: 10.1016/j.mtbio.2025.102620.
46. Dalle Carbonare L, Minoia A, Braggio M, et al. Extracellular vesicles in osteogenesis: comparative analysis of stem cell sources, conditioning strategies, and in vitro models toward advanced bone regeneration. Cells, 2025, 15(1): 27. doi: 10.3390/cells15010027.

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Chinese Journal of Reparative and Reconstructive Surgery

Preservation of necrotic bone structures: an alternative to osteonecrosis of femoral head replacement therapy

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