Invest Clin 65(3): 279 - 293, 2024 https://doi.org/10.54817/IC.v65n3a02

Corresponding author: Dawei Wang, Department of Joint Surgery, Liaocheng People’s Hospital Affiliated to Shan-

dong University, Liaocheng, China. E-mail: wangdawei0120@126.com

A comparative study on the clinical

effectiveness of core decompression with

bone grafting for treating alcohol-induced

and traumatic osteonecrosis of the femoral

head: a population-specific investigation

in alcoholism.

Zhensong Wu

1,2,

Da Song

, Qi Xu

and Dawei Wang

School of Medicine, Shandong University, Jinan, China.

Zaozhuang Municipal Hospital, Zaozhuang, China.

Department of Joint Surgery, Liaocheng People’s Hospital Affiliated to Shandong

University, Liaocheng, China.

Keywords: core decompression; bone grafting; traumatic osteonecrosis of the femoral

head; alcoholic-induced osteonecrosis of the femoral head.

Abstract. Osteonecrosis of the femoral head (ONFH) is a debilitating ortho-

pedic condition with two primary categories: traumatic osteonecrosis (TONFH)

and non-traumatic ONFH, including alcoholic-induced osteonecrosis (AIONFH).

Core decompression combined with bone grafting is a common treatment ap-

proach, but its efficacy and influencing factors in these two categories remain

unclear. We conducted a study involving 50 patients (25 TONFH, 25 AIONFH)

who underwent this procedure. Demographic data and clinical assessments were

collected. The average age was 47.2 years, with 72% males. AIONFH patients had

a higher BMI and more comorbidities like diabetes, hyperlipidemia, hyperten-

sion, and immune-related diseases. TONFH had a higher prevalence of osteopo-

rosis and fracture history. Bilateral hip necrosis was more frequent in TONFH,

while left hip necrosis dominated in AIONFH. Both groups mainly had JIC classi-

fications C1 and C2. Preoperatively, most cases were ARCO grade III and IV, with

lower Harris, PCS, and MCS scores. Both groups improved at the six-month post-

operative assessment, with better results in AIONFH. The last follow-up was 16.62

months after treatment. In the final follow-up, AIONFH cases were mainly ARCO

type I, and HHS, PCS, and MCS scores were significantly better than TONFH.

Core decompression combined with bone grafting effectively treats AIONFH and

TONFH, with superior outcomes in AIONFH. Factors influencing postoperative

efficacy include BMI, JIC classification, and PCS score. These findings provide

valuable insights for tailoring treatment strategies to specific ONFH categories.

280 Wu et al.

Investigación Clínica 65(3): 2024

Análisis comparativo de la eficacia clínica de la descompresión

central combinada con injerto óseo en el tratamiento de la

osteonecrosis traumática o inducida por alcohol de la cabeza

femoral.

Invest Clin 2024; 65 (3): 279 – 293

Palabras clave: descompresión central; injerto óseo; osteonecrosis traumática de la

cabeza femoral; osteonecrosis inducida por alcohol de la cabeza femoral.

Resumen. La osteonecrosis de la cabeza femoral (ONFH) es una afección or-

topédica clasificada en dos categorías principales: osteonecrosis traumática (TON-

FH) y osteonecrosis no traumática, incluida la osteonecrosis inducida por alcohol

(AIONFH). Un estudio con 50 pacientes (25 AIONFH, 25 TONFH) sometidos a des-

compresión central con injerto óseo evaluó su eficacia y factores influyentes. La

edad promedio fue de 47,2 años, con un 72% de hombres y el seguimiento promedio

fue de 16,62 meses. Los pacientes con AIONFH tenían un IMC más alto y más co-

morbilidades como diabetes, hiperlipidemia, hipertensión y enfermedades inmuno-

lógicas. La TONFH tenía una mayor prevalencia de osteoporosis y antecedentes de

fracturas. La necrosis bilateral de cadera fue más frecuente en la TONFH, mientras

que la necrosis de cadera izquierda dominaba en la AIONFH. Ambos grupos tenían

principalmente clasificaciones JIC C1 y C2. Preoperatoriamente, la mayoría de los

casos eran de grado ARCO III y IV, con puntajes de Harris, PCS y MCS más bajos. A

los 6 meses de la evaluación posoperatoria, ambos grupos mejoraron, con resultados

superiores en la AIONFH. El seguimiento promedio fue de 16,62 meses. En la última

evaluación de seguimiento, la mayoría de los casos de AIONFH eran del tipo ARCO

I, y los puntajes de HHS, PCS y MCS fueron significativamente mejores que en la

TONFH. La descompresión central con injerto óseo trata eficazmente ambas cate-

gorías de ONFH, con resultados superiores en la AIONFH. Los factores que influyen

en la eficacia posoperatoria incluyen el IMC, la clasificación JIC y el puntaje PCS.

Estos hallazgos informan sobre la adaptación de las estrategias de tratamiento a las

categorías de ONFH.

Received: 22-09-2023 Accepted: 21-04-2024

INTRODUCCIÓN

Osteonecrosis of the femoral head

(ONFH), or aseptic or avascular necrosis

of the femoral head, is a progressive and

painful orthopedic disease

1,2

. It can be cat-

egorized into traumatic and non-traumatic

osteonecrosis based on its etiology. Non-

traumatic ONFH is associated with various

factors, including alcohol consumption,

glucocorticoid use, infection, bone marrow

infiltrative diseases, blood coagulation disor-

ders, and certain autoimmune diseases

. Ac-

cording to a cross-sectional epidemiological

study on ONFH in China, alcohol, steroids,

and trauma are the three most common

causes, with alcohol-induced non-traumatic

osteonecrosis accounting for 37.15% and

trauma-induced osteonecrosis accounting

for 15.73%

. Regardless of the cause, with-

Comparing treatment for alcohol and trauma-induced femoral head necrosis 281

Vol. 65(3): 279 - 293, 2024

out timely and effective treatment, the dis-

ease can lead to excruciating pain, the col-

lapse of the femoral head, and impaired hip

joint movement, significantly affecting the

patient’s quality of life

Currently, clinical treatments for ONFH

primarily focus on preserving hip joint func-

tion and halting disease progression. Various

treatment modalities exist, including total

hip arthroplasty, core decompression, vas-

cularized and non-vascularized bone trans-

plantation, and different osteotomy proce-

dures

. Each treatment approach presents

its advantages and drawbacks. Among these

options, core decompression stands out as

an ideal method, particularly for patients

with early-stage ONFH

. This technique en-

tails the removal of necrotic tissue from the

femoral head, thereby reducing intraosseous

pressure, promoting vascular reconstruc-

tion, facilitating bone regeneration within

the necrotic region, relieving bone edema,

and improving blood supply to the femoral

head to foster lesion repair

8-10

However, it should be noted that both

thick channel core decompression and fine

needle multi-hole drilling decompression

procedures may inadvertently compromise

the mechanical properties of the already

fragile subchondral bone during the opera-

tion. Consequently, this may accelerate the

collapse of the load-bearing surface of the

femoral head or lead to subchondral bone

fractures

11,12

. Combining core decompres-

sion with bone grafting has emerged as a vi-

able solution to address this issue. Incorpo-

rating bone grafts into the necrotic segment

after decompression provides structural sup-

port, facilitating subchondral bone recon-

struction in the femoral head and mitigating

the risk of cartilage collapse

. It is essen-

tial to recognize that the etiology of ONFH

may vary, potentially impacting the clinical

efficacy of core decompression combined

with bone grafting. Thus, this study aims to

analyze patients with alcohol-related ONFH

(AIONFH) and traumatic ONFH (TONFH) to

compare the clinical outcomes of core de-

compression combined with bone grafting in

both types of patients and identify relevant

factors. This research offers valuable insights

to enhance the accuracy of the clinical ap-

plication of core decompression and bone

grafting for patients with ONFH.

MATERIAL AND METHODS

Subject Recruitment and Surgical Proce-

dure

For this study, 50 patients were recruit-

ed based on strict inclusion and exclusion

criteria. Twenty-five patients (35 hips) with

TONFH were randomly selected to form the

TONFH group, while another 25 patients (34

hips) diagnosed with AIONFH were chosen

to constitute the AIONFH group.

All recruited patients underwent sur-

gery under general anesthesia, assuming

a supine position. The iliac crest served as

the designated operation site. Prior to sur-

gery, routine disinfection and towel laying

were performed. The surgical procedure

commenced with a layered tissue incision

to expose the iliac crest. Subsequently, the

iliac bone was removed using a bone knife,

crushed with rongeurs, and rinsed with nor-

mal saline. Following this, a guide needle

was used to puncture the necrotic site along

the vertex of the greater trochanter of the

femur, approximately 2 cm in length. Ne-

crotic tissue was carefully scraped off from

the site. Bone grafting material, composed

of a mixture of the just removed bone tis-

sue and artificial bone, was then crushed and

implanted into the necrotic area, ensuring

complete filling. Attention was given to con-

firm adequate filling of the bone graft, and

any remaining bone tissue was placed into

the channel. The wound was finally rinsed

and sutured. Postoperatively, all patients

were required to remain in bed for one

month, after which they resumed limited ac-

tivity combined with appropriate functional

exercise. From three months post-surgery

to six months post-surgery, patients utilized

walking aids to increase weight-bearing ex-

282 Wu et al.

Investigación Clínica 65(3): 2024

ercise gradually. Whole weight-bearing exer-

cise was used after six months post-surgery.

Inclusion criteria

1. Patients with a confirmed diagnosis

of ONFH through imaging and clinical ex-

aminations. 2. Patients with ONFH caused

either by alcohol consumption or traumatic

incidents. 3. Patients who underwent core

decompression combined with bone grafting

as a treatment modality. 4. Patients who pro-

vided informed consent after being informed

about the study.

Exclusion criteria

1. Patients with ONFH caused by hor-

monal imbalances or inflammation. 2. Pa-

tients who underwent treatment methods

unrelated to core decompression combined

with bone grafting. 3. Patients with an insuf-

ficient matching degree or lacking relevant

case data. 4. Patients with severe conditions

such as malignant tumors or hemorrhagic

diseases.

Main observation index

This study utilized the hospital medical

record system to gather crucial patient in-

formation, medical records during hospital-

ization, preoperative and postoperative im-

aging data, postoperative adverse reactions,

and follow-up records. The primary data of

patients, including sex, age, height, weight,

body mass index (BMI), and complications,

were collected. All patients underwent an

impact examination upon admission, and

regular follow-ups were conducted after the

operation to assess the presence of necrosis

and collapse of the femoral head. The classi-

fication system used for ONFH was based on

the Japanese Investigation Committee, JIC

classification.

The clinical efficacy was evaluated

through the Association Research Circula-

tion Osseous (ARCO) classification, Harris

Hips score (HHS), and SF-36 scale before the

operation and the follow-up at six months af-

ter and at the last follow-up.

The ARCO classification served as a

means to categorize ONFH, providing in-

sight into the surgical effect and enabling

targeted adjustments to the treatment

plan. In this study, the ARCO 2019 staging

method was employed

, dividing patients

into four stages (I, II, III and IV) based on

imaging examination results and patho-

logical changes in the femoral head. Stage

I showed abnormalities in X-ray examina-

tion, while MRI indicated a banded low sig-

nal surrounding the necrotic area. Stage IV

was characterized by evident osteoarthritis,

with an X-ray examination revealing bone-

joint space narrowing, acetabular changes,

and joint destruction.

HHS was utilized to evaluate the hip

joint function, encompassing four aspects:

pain degree (44 points), joint function (47

points), deformity (4 points), and range of

motion (5 points). A higher score indicated

better hip joint function, with scores less

than 70 points indicating poor function,

scores between 70 and 79 indicating medi-

um-level function, scores between 80 and 89

indicating good function, and scores of 90-

100 indicating excellent function.

The SF-36 scale was employed to as-

sess patients’ quality of life, covering eight

aspects: physiological function, emotional

function, physical pain, general health sta-

tus, experience, social function, and mental

health. The SF-36 conversion equation of

the Chinese population published by Lam

et al. was used to convert the questionnaire

responses into physical health score (PCS)

and mental health score (MCS), with higher

scores indicating a better quality of life.

Additionally, the therapeutic effect

was evaluated based on the results of the

last follow-up, with patients without data at

the last follow-up being analyzed using data

from 6 months after the operation. The ef-

fectiveness of treatment was categorized as

follows: “Extremely effective”, indicating

increased bone mineral density in the fo-

cus, with the cystic light transmission area

and fissure sign returning to normal, and

Comparing treatment for alcohol and trauma-induced femoral head necrosis 283

Vol. 65(3): 279 - 293, 2024

no collapse of the femoral head; “Effective”,

indicating increased bone mineral density

in the focus, with the cystic light transmis-

sion area and fissure sign decreased, and

femoral head collapse < 2mm; and “Inef-

fective,” indicating femoral head collapse

≥ 2mm. The effective rate of treatment

was calculated by summing the number of

patients classified as “Extremely effective”

and “Effective”.

Statistical analysis

Data entry and collation of the ques-

tionnaire were performed using Excel soft-

ware, while statistical data analysis was con-

ducted using Statistic Package for Social

Science (SPSS) 25.0 ® (IBM, Armonk, NY,

USA). Continuous variables and classified

variables in the study were described and

analyzed in the form of “average ± standard

deviation” and “cases (proportion),” respec-

tively. For continuous variables conforming

to the normal distribution, the independent

sample T-test was employed to analyze differ-

ences between groups, while those not con-

forming to the normal distribution were an-

alyzed using the Mann-Whitney U test. The

classified variables were subjected to sta-

tistical analysis using the chi-square test or

Fisher exact test. Univariate Logistic regres-

sion analysis was used to identify risk factors

affecting treatment efficacy, while multivari-

ate logistic regression analysis was employed

to analyze significant indicators. Statistical

results with p<0.05 were considered to have

a significant difference in the data.

RESULTS

Study Characteristics

This study presents the patients’ basic

information and clinical characteristics, as

outlined in Table 1. The average age of the

patients included in the study was 47.2 ±

7.4 years, with a majority of male patients

(72.0%). The BMI of the patients in the

AIONFH group was significantly higher than

that of the patients in the TONFH group

(p<0.05). The prevalence of diabetes, hy-

perlipidemia, hypertension, and immune-

related diseases was higher in the AIONFH

group compared to the TONFH group, while

the history of osteoporosis and fracture was

more frequent in the TONFH group. Regard-

ing postoperative adverse reactions, both

groups experienced a higher occurrence of

severe pain and deep venous thrombosis at

the last follow-up, and there was no signifi-

cant difference between the two groups (p

>0.05).

Imaging Features

The imaging results for both groups are

detailed in Table 1. Among the patients in

the TONFH group, 40.00% exhibited necro-

sis in both hip joints, while in the AIONFH

group, 40.00% displayed necrosis in the

left hip joint. According to the JIC classifi-

cation, many patients in both groups were

categorized as C1 and C2 types. Specifically,

the TONFH group had a higher proportion

of C2 type (45.71%) compared to C1 type

(34.29%), whereas both C1 and C2 types

were equally distributed in the AIONFH

group (38.24%). No significant difference

between the two groups was observed in hip

joint pathological changes and JIC classifi-

cation.

Comparison of ARCO classification, HHS

and SF-36 score between the two groups

before operation

Results of ARCO classification, HHS,

and SF-36 score for both groups before the

operation are presented in Table 2. No sig-

nificant difference was found in the above in-

dexes between the two groups before the op-

eration (p>0.05). The most common ARCO

classification in both groups was Grade IV.

In terms of Harris score, the scores for both

groups were significantly lower than 70, in-

dicating poor hip joint function.

284 Wu et al.

Investigación Clínica 65(3): 2024

Table 1

Basic information and clinical characteristics of patients.

Variables Total TONFH Group AIONFH Group t/Z/χ

/F p

Patients/hips 50/69 25/35 25/34

Age

(year, mean ± SD)

47.2±7.4

45.6±8.2

48.8±6.2

1.528

0.133

Gender

n (%)

Male 36 (72) 16 (64) 20(80) 1.587 0.208

Female 14 (28) 9 (36) 5(20)

BMI

(kg/m

, mean ± SD)

23.81±2.49

22.85±2.54

24.78±2.06

2.949 0.005

Smoking n (%) 27(54) 13(52) 14(56) 0.081 0.777

Alcohol

n (%)

40(80)

15(60)

25(100)

12.500

<0.001

Pathogeny

n (%)

Alcohol 25(50) - 25(100) - -

Trauma 21(42) 21(84) -

Others 4(8) 4(16) -

Complications /

existing medical

history

n (%)

Diabetes 23(46) 9(36) 14(56) 22.543 <0.001

Hyperlipidemia 27(54) 9(36) 18(72)

Hypertension 28(56) 10(40) 16(64)

Immune-related

diseases

19(38)

7(28)

12(48)

Osteoporosis 26(52) 14(56) 12(48)

Fracture 23(46) 21(84) 2(8)

Necrotic hip joint

n (%)

Left 18(26.09) 8(32) 10(40) 0.352 0.839

Right 13(18.84) 7(28) 6(24)

Both 19(27.54) 10(40) 9(36)

JIC classification

n (%)

A 7(10.14) 4(11.43) 3(8.82) 0.985 0.805

B 8(11.59) 3(8.57) 5(14.71)

C1 25(36.23) 12(34.29) 13(38.24)

C2 29(42.03) 16(45.71) 13(38.24)

Postoperative

adverse reactions

n (%)

Severe pain 8(16) 4(16) 4(16) 0.287 0.963

Infected 2(4) 1(4) 1(4)

Deep venous

thrombosis

6(12) 3(12) 3(12)

Hematoma 3(6) 1(4) 2(8)

Follow-up time

(month, mean ± SD)

16.62±5.21

17.04±5.22

16.2±5.28

0.566

0.574

p<0.05 indicates statistical significance.

For continuous variables conforming to the normal distribution, the independent sample T-test was employed to

analyze differences between groups, while those not conforming to the normal distribution were analyzed using the

Mann-Whitney U test. The classified variables were subjected to statistical analysis using the chi-square test or Fis-

her exact test; Traumatic osteonecrosis (TONFH); non-traumatic- alcoholic-induced osteonecrosis (AIONFH). BMI:

body mass index; JIC: Japanese Investigation Committee Classification.

Comparing treatment for alcohol and trauma-induced femoral head necrosis 285

Vol. 65(3): 279 - 293, 2024

Comparison of ARCO classification,

HHS and SF-36 score between the two

groups of the follow-up at 6 months after

operation

Six months after the operation, the re-

sults of ARCO classification, HHS, and SF-36

score for both groups are shown in Table 3.

However, it is worth noting that one patient

in the TONFH group could not be reached

for follow-up, reducing the number of pa-

tients/hips to 24/34 in this group.

In terms of ARCO typing, a majority

of patients in the AIONFH group were clas-

sified as type III (61.76%), while those in

the TONFH group still belonged to grade

IV (38.24%). This difference between the

two groups was statistically significant (p <

0.05). The total HHS for the AIONFH group

was (73.24 ± 8.45), indicating a significant

improvement in hip joint function for these

patients. On the other hand, the Harris score

for the TONFH group remained lower than

70 (p<0.05), indicating persistent poor hip

joint function. Moreover, the scores of PCS

and MCS in the AIONFH group were higher

compared to those in the TONFH group, and

the difference in MCS scores was found to be

significant. This suggests that patients with

AIONFH experienced better physical and

mental health outcomes compared to those

with TONFH.

Comparison of ARCO classification, HHS

and SF-36 score between the two groups

at the last follow-up

At the last follow-up, the results of ARCO

classification, Harris score, and SF-36 score

for both groups are presented in Table 4. It

should be noted that during the last follow-

up, two patients in the TONFH group and

four patients in the AIONFH group could not

be contacted normally, reducing the number

of patients/hip joints to 22/31 and 21/29.

At the last follow-up, significant differ-

ences were observed in the results of all three

indexes between the AIONFH and TONFH

Table 2

Comparison of ARCO classification, HHS and SF-36 score between the two groups before operation.

Variables TONFH Group AIONFH Group t/Z/χ

Patients/hips 25/35 25/34

ARCO n (%)

I/II

3 (8.57) 3 (8.82) 0.825 0.662

III 8 (22.86) 11(32.35)

IV 24 (68.57) 20 (58.82)

HHS (score, mean ± SD) Pain 21.4±2.72 21.09±3.18 0.691 0.490

Function 23.31±3.34 23.65±2.59 0.461 0.646

Deformity 4±0 4±0 - -

Range of motion 0.6±0.65 0.59±0.5 0.190 0.849

Total scores 49.31±5.11 49.32±5.76 0.007 0.994

SF-36 (score, mean ± SD) PCS 32.64±2.89 32.04±2.73 0.755 0.454

MCS 43.48±1.85 43.04±3.52 0.553 0.583

p<0.05 indicates statistical significance.

For continuous variables conforming to the normal distribution, the independent sample T-test was employed to

analyze differences between groups, while those not conforming to the normal distribution were analyzed using

the Mann-Whitney U test. The classified variables were subjected to statistical analysis using the chi-square test or

Fisher exact test.

Traumatic osteonecrosis (TONFH) ; non-traumatic-alcoholic-induced osteonecrosis (AIONFH). ARCO: Association

Research Circulation Osseous; HHS: Harris Hip Score; SF-36: 36-Item Short Form Health Survey.

286 Wu et al.

Investigación Clínica 65(3): 2024

groups (p<0.05). In the AIONFH group, most

patients were classified as type I according

to the ARCO classification (43.33%), while

most patients in the TONFH group were clas-

sified as type II (38.71%). This difference in

ARCO classification between the two groups

was statistically significant. The HHS of pa-

tients in both groups were higher than 70,

indicating improved hip joint function. How-

ever, the Harris scores in the AIONFH group

were notably higher than 80. Furthermore,

the scores of PCS and MCS in the AIONFH

group were significantly higher than those in

the TONFH group.

Therapeutic effect of two groups

of patients

The therapeutic effects of the two

groups are shown in Table 5. The total effec-

tive rate of the AIONFH group was 76.47%,

which was higher than that of TONFH group

(55.88%).

Analysis of the related factors affecting

the prognosis of patients

Table 6 presents the results of the Lo-

gistic regression analysis conducted to iden-

tify possible factors related to the prognosis

of patients. The univariate Logistic analysis

examined several factors, including BMI,

immune-related diseases, history of osteo-

porosis, JIC classification, HHS, PCS, and

MCS. The analysis revealed that these fac-

tors showed statistical significance concern-

ing the prognosis of patients.

Upon further analysis using multivari-

ate Logistic regression, three factors were

statistically significant predictors of progno-

sis. These factors were BMI, JIC classifica-

tion, and PCS.

Table 3

Comparison of ARCO classification, HHS and SF-36 score between

the two groups 6 months after operation.

Variables TONFH Group AIONFH Group t/Z /χ2 p

Patients/Hips 24/34 25/34

ARCO n (%) I 1(2.94) 5(14.71) 15.156 0.002

II 11(32.35) 5(14.71)

III 9(26.47) 21(61.76)

IV 13(38.24) 4(11.76)

HHS

(score, mean ± SD)

Pain 25.59±2.73 32.85±3.81 5.881 <0.001

Function 27.76±3.96 34.76±4.63 6.701 <0.001

Deformity 4±0 4±0 - -

Range of motion 1.26±0.45 1.62±0.92 1.416 0.157

Total scores 61.62±5.83 73.24±8.45 6.600 <0.001

SF-36

(score, mean ± SD)

PCS 36.21±4.49 38.08±4.73 1.529 0.126

MCS 45.25±2.77 47.52±4.82 2.030 0.049

p<0.05 indicates statistical significance.

For continuous variables conforming to the normal distribution, the independent sample T-test was employed to

analyze differences between groups, while those not conforming to the normal distribution were analyzed using

the Mann-Whitney U test. The classified variables were subjected to statistical analysis using the chi-square test or

Fisher exact test.

Traumatic osteonecrosis (TONFH); non-traumatic- alcoholic-induced osteonecrosis (AIONFH). ARCO: Association

Research Circulation Osseous; HHS: Harris Hip Score; SF-36: 36-Item Short Form Health Survey.

Comparing treatment for alcohol and trauma-induced femoral head necrosis 287

Vol. 65(3): 279 - 293, 2024

DISCUSSION

Core decompression combined with bone

grafting is ideal for treating AIONFH

and TONFH

ONFH is a challenging orthopedic con-

dition with a high disability rate, necessitat-

ing timely and effective treatment to pre-

serve patients’ health and quality of life

Among various treatment approaches, core

decompression and bone grafting are con-

sidered favorable surgical methods

. The

combination of these techniques not only re-

duces internal pressure in the femoral head,

alleviates bone marrow edema, and enhanc-

es intraosseous microcirculation through

Table 4

Comparison of ARCO/ classification, HHS and SF-36 score between the two groups

at six months after the last follow-up.

Variables TONFH Group AIONFH Group Z /χ

Patients/Hips 22/31 21/29

ARCO▲ n (%) I 3(9.68) 13(43.33) 10.806 0.013

II 12(38.71) 10(33.33)

III 5(16.13) 3(10)

IV 11(35.48) 4 (13.33)

HHS▲

(score, mean ± SD)

Pain 32.58±5.1 36.83±6.29 3.225 0.001

Function 35.39±7.28 40.00±6.26 3.100 0.002

Deformity 3.77±0.43 3.86±0.35 0.872 0.383

Range of motion 3.13±1.71 3.59±1.4 0.713 0.476

Total scores 74.87±14.17 84.28±13.99 2.791 0.005

SF-36▲

(score, mean ± SD)

PCS

41.86±8.35 45.86±7.32 2.296 0.022

MCS 47.26±3.78 50.27±5.48 2.088 0.037

▲

The results were compared with the corresponding indexes of this group before operation, p< 0.05; p<0.05.

For continuous variables conforming to the normal distribution, the independent sample T-test was employed to

analyze differences between groups, while those not conforming to the normal distribution were analyzed using

the Mann-Whitney U test. The classified variables were subjected to statistical analysis using the chi-square test or

Fisher exact test.

Traumatic osteonecrosis (TONFH); non-traumatic- alcoholic-induced osteonecrosis (AIONFH). ARCO: Association

Research Circulation Osseous; HHS: Harris Hip Score; SF-36: 36-Item Short Form Health Survey.

Table 5

Clinical treatment of patients in two groups.

Groups Extremely effective Effective Ineffective Total efficiency

TONFH Group (34 hips) 15(44.12)* 4(11.76) 15 (44.12) 19 (55.88)

AIONFH Group (34 hips) 23(67.65) 3(8.82) 8 (23.53) 26 (76.47)

value 3.219

p value 0.073

* n (%).

p<0.05 indicates statistical significance.

Traumatic osteonecrosis (TONFH); non-traumatic- alcoholic-induced osteonecrosis (AIONFH).

The classified variables were subjected to statistical analysis using the chi-square test or Fisher exact test.

288 Wu et al.

Investigación Clínica 65(3): 2024

improved muscle and pulse reflux but also

facilitates osteogenesis, bone repair, and

provides structural support to the femoral

head, thereby reducing the risk of postop-

erative femoral head collapse

Prior research by Larson et al. indicated

that using core decompression alone to treat

ONFH yields variable clinical success rates,

with the lowest rate being only 20%, leading

to uncertain therapeutic outcomes

. How-

ever, our study demonstrates that combin-

ing core decompression with bone grafting

yields better therapeutic results for patients

with AIONFH and TONFH, achieving 55.88%

and 76.47% success rates. By comparing

various indices before surgery, at six months

after the operation, and at the last follow-up,

we observed an improvement in the ARCO

classification from grade III/IV to grade I/

II in both groups. The HHS and SF-36 scores

were also significantly enhanced, indicating

notable improvements in hip joint function

and overall quality of life. The ARCO classifi-

cation system is widely used to assess ONFH

and reflects the occurrence of femoral head

collapse

5,19

. The HHS provides a comprehen-

sive evaluation of post-surgery hip joint func-

tion. The combination of these assessments

effectively captures the hip joint’s recovery

and the overall well-being of the patients

The SF-36 scale is a reliable tool for measur-

ing health-related quality of life

, and when

combined with the other measures, it high-

lights the substantial positive impact of the

surgical intervention on the patient’s func-

tional recovery and psychological well-being.

Table 6

Logistic regression analysis of factors related to prognosis of patients.

Predictor Univariables OR (95% CI) p Multivariables OR (95% CI) p

Pathogeny 2.566(0.905-7.275) 0.076

Gender 0.653(0.21-2.027) 0.461

Age 0.979(0.906-1.059) 0.602

BMI 0.723(0.571-0.915) 0.007 0.692(0.507-0.944) 0.020*

Smoking 2.141(0.771-5.945) 0.144

Alcohol 0.389(0.128-1.181) 0.096

Diabetes 2.612(0.902-7.569) 0.077

Hyperlipidemia 1.146(0.418-3.138) 0.791

Hypertension 1.95(0.705-5.394) 0.198

Immune-related diseases 0.28(0.097-0.805) 0.018 0.133(0.007-2.47) 0.176

Osteoporosis 0.222(0.07-0.703) 0.011 3.365(0.536-21.125) 0.195

Fracture 0.429(0.153-1.198) 0.106

JIC 5.526(1.726-17.692) 0.004 14.275(1.117-182.387) 0.041*

HHS 0.811(0.707-0.93) 0.003 0.779(0.594-1.023) 0.072

PCS 0.581(0.432-0.78) <0.001 0.419(0.192-0.913) 0.029*

MCS 0.674(0.52-0.875) 0.003 0.781(0.475-1.284) 0.330

*p<0.05.

Univariate Logistic regression analysis was used to identify risk factors affecting treatment efficacy, while multiva-

riate Logistic regression analysis was employed to analyze significant indicators.

Body mass index (BMI); JIC: Japanese Investigation Committee; HHS: Harris Hip Score; Physical Health Score

(PCS); Mental Health Score (MCS).

Comparing treatment for alcohol and trauma-induced femoral head necrosis 289

Vol. 65(3): 279 - 293, 2024

Core decompression combined with bone

grafting has a better therapeutic effect

on AIONFH

Upon further analysis, we observed that

the therapeutic efficacy of core decompres-

sion combined with bone grafting was su-

perior in patients with AIONFH compared

to those with TONFH. TONFH is gener-

ally caused by direct trauma to the femoral

head, leading to the disruption of blood sup-

ply, ischemia, and hypoxia of osteocytes, ul-

timately resulting in necrosis

. The blood

supply to the femoral head is primarily from

the medial and lateral circumflex femoral

arteries, which supply blood to the lateral

anterior superior region and the area below

the femoral head. Fractures, particularly in

the femoral neck region, can damage these

arteries, increasing the likelihood of ONFH.

On the other hand, AIONFH arises

mainly from an imbalance in osteogenesis/

osteoclast activity and abnormal lipid me-

tabolism, causing ischemia, hypoxia, venous

stasis, and elevated intraosseous pressure

in the femoral head

23,24

. Considering the

unique characteristics of core decompres-

sion combined with bone grafting and the

distinct pathological nature of the two dis-

eases, this treatment approach holds greater

promise for managing AIONFH. Our study

supports this notion, as the total effective

rate in the AIONFH group was higher than

that in the TONFH group. Moreover, starting

from six months after the operation, many

indices in the AIONFH group showed better

outcomes than those in the TONFH group.

At the last follow-up, except for “deformity”

and “range of motion” in the Harris score,

all other indices demonstrated significant

improvement in the AIONFH group com-

pared to the TONFH group. These findings

suggest that core decompression combined

with bone grafting yields superior clinical ef-

ficacy in treating AIONFH, leading to more

pronounced improvements in the patients’

quality of life.

Overall, the results indicate that the

chosen treatment approach is more advanta-

geous for AIONFH patients due to its ability

to address the disease’s specific pathological

mechanisms. This study highlights the im-

portance of selecting appropriate treatment

strategies tailored to the unique character-

istics of different types of femoral head ne-

crosis, ultimately leading to better clinical

outcomes and improved patient well-being.

BMI, JIC classification and PCS score are

the risk factors affecting the prognosis

of patients

Our results also indicated that BMI, JIC

classification, and PCS score could be poten-

tial risk factors influencing the prognosis of

patients with AIONFH and TONFH. BMI is

a commonly used indicator to assess body

weight and is employed to evaluate various

health conditions

, including obesity and

the risk of fractures

, hypertension

, and

kidney disease

. Prior studies have high-

lighted the crucial role of lipid metabolism

in the development of femoral head osteone-

crosis. Lowering body fat content has been

shown to enhance osteogenesis, while lipid

metabolism disorders may lead to fat enter-

ing the bloodstream and spreading through-

out the body, potentially affecting bone mar-

row and increasing intramedullary pressure.

This process could obstruct venous reflux

and impede blood circulation within bone

tissue, ultimately influencing the clinical ef-

fectiveness of intramedullary decompression

combined with bone grafting. Hence, higher

BMI levels may impact the treatment out-

comes of this surgical approach.

Additionally, the location of the ne-

crotic area within the femoral head is closely

associated with femoral head collapse and

pain

29,30

. When the osteonecrosis area is lo-

cated inside the weight-bearing region, the

subchondral bone remains more intact, en-

hancing femoral head stability and reduc-

ing pain and collapse rates during weight-

bearing

31,32

. On the contrary, when the JIC

classification of the patient indicates type C,

where the necrotic area is situated outside

the weight-bearing region, patients tend to

290 Wu et al.

Investigación Clínica 65(3): 2024

experience more severe pain, and the proba-

bility of postoperative femoral head collapse

is higher. Therefore, the JIC classification

serves as an effective index for predicting

the prognosis of patients.

Furthermore, the PCS score reflects

patients’ physical health and indirectly indi-

cates the impact of femoral head osteone-

crosis on their life. Patients’ quality of life is

often closely related to the severity and du-

ration of the disease and the stress caused by

. As a result, the PCS score can provide

insights into the patient’s overall condition

and prognosis, helping to gauge the severity

of the disease and its impact on the patient’s

well-being.

Considering BMI, JIC classification,

and PCS score as potential risk factors in

the prognosis of AIONFH and TONFH pa-

tients can aid in understanding their clini-

cal outcomes and developing appropriate

treatment strategies tailored to their spe-

cific conditions. The findings of this study

underscore the efficacy of core decompres-

sion combined with bone grafting in treat-

ing avascular necrosis of the femoral head

(ONFH), particularly in the context of al-

cohol-induced ONFH. While the results of

this study support the positive outcomes of

this surgical technique, it is essential to ac-

knowledge that the focus on alcohol-induced

ONFH necessitates specific consideration

of the population studied. Given the epide-

miological significance of alcohol-induced

ONFH in specific populations, it is crucial to

emphasize the specificity of this study’s find-

ings to the alcoholism-related etiology in

the title of the manuscript. By recognizing

the unique epidemiological aspects of the

study population, the results and implica-

tions can be more accurately contextualized

and better aligned with the specific medical-

metabolic origins of alcohol-induced ONFH.

While the current study included as-

sessments at preoperative, six months

postoperative, and a final follow-up, we ac-

knowledge the need for more frequent and

intermediate medical controls during the

postoperative period. Therefore, it is recom-

mended to incorporate interim assessments

at specific intervals, such as three months

and 12 months postoperatively, to provide

a more comprehensive understanding of

the progression and outcomes of the surgi-

cal treatment. These additional checkpoints

will allow for a more nuanced evaluation

of the patient’s recovery and the effective-

ness of the intervention, particularly in the

context of the described surgical treatment

approach for osteonecrosis of the femoral

head. Further, it is imperative to acknowl-

edge the significance of utilizing additional

assessment scales, including imaging-based

evaluations, alongside standard clinical rat-

ing scales for a comprehensive evaluation

of treatment outcomes in osteonecrosis of

the femoral head. While the study incorpo-

rated reliable and internationally recognized

clinical rating scales such as the Associa-

tion Research Circulation Osseous (ARCO)

classification, Harris Hip Score (HHS), and

SF-36 scale, the inclusion of imaging-based

assessments, such as MRI and X-ray evalua-

tions, would provide valuable insights into

the structural changes and healing progres-

sion within the femoral head post-surgery.

The integration of imaging assessments

will offer a more holistic understanding of

the treatment response and aid in deter-

mining the success of the surgical interven-

tion from both functional and anatomical

perspectives. Therefore, it is recommended

to consider including imaging-based evalu-

ation tools as supplementary measures to

augment the comprehensive assessment of

treatment outcomes in future research en-

deavors. Besides, this study included its fo-

cus on a specific population and etiological

factors, which may restrict the generalizabil-

ity of the findings to other populations and

ONFH etiologies.

In conclusion, core decompression

combined with bone grafting has demon-

strated promising therapeutic outcomes for

AIONFH and TONFH, with particularly sig-

nificant results observed in AIONFH cases.

Comparing treatment for alcohol and trauma-induced femoral head necrosis 291

Vol. 65(3): 279 - 293, 2024

This treatment approach improves hip joint

function and effectively enhances patients’

overall quality of life while mitigating the

risk of postoperative femoral head collapse.

Consequently, it is a recommended surgical

method for managing these conditions.

Moreover, our findings suggest that

BMI, JIC classification, and PCS score may

serve as potential risk factors influencing

the prognosis of patients with AIONFH and

TONFH. Patients who present with specific

indicators related to these factors should

receive heightened attention and suitable

treatment measures to improve the sur-

gery’s clinical effectiveness and prognostic

outcomes. Furthermore, as medical advance-

ments continue to progress, the availability

of various bone grafting options has expand-

ed. Building upon the established efficacy

of core decompression combined with bone

grafting in treating AIONFH, further explo-

ration into different types of bone grafts may

offer additional opportunities for treatment

optimization.

Conflict of interests

The authors declared no conflict of in-

terest.

Author’s ORCID numbers

• Zhensong Wu (ZW):

0009-0009-2940-0781

• Da Song (DA):

0009-0004-2242-2498

• Qi Xu (QX):

0009-0001-5704-582X

• Dawei Wang (DW):

0009-0001-4508-790X

Participation in development

and writing of the paper

Concept and design: ZW and DW. Ac-

quisition of data, literature review, and re-

finement of manuscript: All authors. Analy-

sis and interpretation of data: DS and QX.

Manuscript writing: ZW. Review of final man-

uscript: DW.

Funding

No funds, grants, or other support was

received.

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