International Orthopaedics

, Volume 42, Issue 12, pp 2737–2743 | Cite as

No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis

  • Byung-Ho Yoon
  • Young-Kyun Lee
  • Ki-Choul KimEmail author
  • Yong-Chan Ha
  • Kyung-Hoi Koo
Original Paper



Core decompression (CD) has been used to treat early-stage (pre-collapse) osteonecrosis of the femoral head (ONFH) in an attempt to prevent collapse. Recently, other adjunctive treatments including bone grafting (BG) and bone marrow mononuclear cells (BMMC) were combined to traditional CD to improve the results. We assessed the efficacy of various CD modalities and non-operative treatment through a network meta-analysis (NMA).


Nine randomized controlled trials with a minimum two year follow-up were retrieved from PubMed, Embase, and Cochrane Library search. Treatment modalities categorized into five; (1) traditional CD alone, (2) CD combining BG, (3) CD combining BMMC, (4) CD combining BG and BMMC, and (5) non-operative treatment. The rate of conversion to total hip arthroplasty (THA) and the radiologic progression were compared among the five treatments.


A total of 453 hips were included in our NMA; 151 hips in CD, 70 hips in CD combining BG, 116 hips in CD combining BMMC, 25 hips in CD combining BG and BMMC, and 91 hips in non-operative treatment. There were no differences in the rate of THA conversion across all five treatment modalities. The pooled risk ratio compared with non-operative treatment for THA conversion was 0.92 (95% CI, 0.19–4.43; p = 0.915) in traditional CD; 4.10 (95% CI, 0.37–45.42; p = 0.250) in CD combining BG; 0.30 (95% CI, 0.04–2.49; p = 0.267) in CD combining BMMC; and 1.78 (95% CI, 0.05–63.34; p = 0.750) in CD combining BG and BMMC. No significant differences were found in terms of the radiologic progression across all treatments.


In the current NMA, we did not find any differences in the rates of THA conversion and radiologic progression across all CD modalities and non-operative treatment. These results question the assumption that CD changes the natural course of ONFH. Considering that size of necrotic portion is the major determinant of future collapse of the necrotic femoral head and the collapse does not occur in small lesions even without any treatment, a large-scale randomized controlled trial is necessary to confirm the effectiveness of CD.

Level of evidence

Level I, meta-analysis.


Hip Osteonecrosis Avascular necrosis Core decompression Network Meta-analysis 



There is no funding source.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.


None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.

Supplementary material

264_2018_3977_MOESM1_ESM.docx (20 kb)
ESM 1 Updated checklist for network meta-analysis of randomized clinical trials. (DOCX 19 kb)
264_2018_3977_MOESM2_ESM.docx (294 kb)
ESM 2 The search strategy that details the searching process of relevant clinical study selection. (DOCX 293 kb)
264_2018_3977_MOESM3_ESM.jpg (7 kb)
ESM 3 Risk of graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies. (JPG 7 kb)


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Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Byung-Ho Yoon
    • 1
  • Young-Kyun Lee
    • 2
  • Ki-Choul Kim
    • 3
    Email author
  • Yong-Chan Ha
    • 4
  • Kyung-Hoi Koo
    • 2
  1. 1.Department of Orthopaedic SurgeryInje University College of Medicine, Seoul Paik HospitalSeoulSouth Korea
  2. 2.Department of Orthopaedic SurgerySeoul National University Bundang HospitalSeongnamSouth Korea
  3. 3.Department of Orthopaedic SurgeryDankook University College of MedicineCheonan-siSouth Korea
  4. 4.Department of Orthopaedic SurgeryChung-Ang University College of MedicineSeoulSouth Korea

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