Autologous grafts in the treatment of avascular osteonecrosis of the femoral head

Main Article Content

Marco Marcarelli
Marco Fiammengo
Letizia Trovato
Vincenzo Lancione
Elvio Novarese
Pier Francesco Indelli
Salvatore Risitano


autologous, micrografts, bone regeneration, conservative treatment, osteonecrosis, femoral head


Background: Osteonecrosis of the femoral head (ONFH) is a frequent orthopedic disease leading to destruction of the hip joint and disabling arthritis. Several procedures have been developed to treat the joint deterioration in case of osteonecrosis, trying to avoid or delay an intervention of total hip replacement, especially in young patients. The aim of this study was to analyze the use of autologous bone micrografts derived from cancellous bone in the management of avascular ONFH. The treatment described was implemented using the Rigenera® protocol to obtain autologous micrografts: small fragments of cancellous bone collected by femoral neck, disaggregated and injected in the necrotic area using an empty screw. Materials and methods: Twenty adult patients affected by avascular ONFH were enrolled in this study; all patients reported a preoperative intermittent coxo-arthrosis and limited function of intra and extra rotation of the hip. Inclusion criteria were an Oxford Hip Score between (OHS) 20 and 39, a Harris hip score (HHS) showing pre-operative poor results (lower than 70 points) and a stage II-IIIA and IIIB according with the classification proposed by the Association Research Circulation Osseous (ARCO). Results: Using an MRI evaluation, after six months, the authors observed a complete regression of necrotic area and the restoration of osseous structure. Clinical outcome has been evaluated at 6-12 and 24 months follow-up. At the final F.U. the HHS rised from poor to good results (mean value at final F.U of 84) while the OHS improved significantly already after 21 days from micrografts injection (mean 35.4 ± 7.5) with an increasing trend  until to two-year final FU (mean 37.4 ± 9.5). The full recovery of daily and mild sport activities was reached after 20 and 90 days from intervention, respectively. Conclusion: The results of this study are suggestive for a new approach in the treatment of avascular ONFH assuming a process of bone regeneration based on a dual mechanism of action, biological and mechanical, induced by micrografts and injected using an empty screw as vehicle.


Download data is not yet available.
Abstract 491 | PDF Downloads 190


[1] Gangji V, Hauzeur JP, Matos C, De Maertelaer V, Toungouz M, Lambermont M. (2004) Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study. J Bone Joint Surg Am 86-A(6):1153-60.
[2] Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. (2015) Current concepts on osteonecrosis of the femoral head. World J Orthop 6:590e601.
[3] Zalavras CG, Lieberman JR. (2014) Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg 22(7):455-64. doi: 10.5435/JAAOS-22-07-455.
[4] Choi HR, Steinberg ME, Cheng E. (2015) Osteonecrosis of the femoral head: diagnosis and classification systems. Curr Rev Musculoskelet Med 8(3):210-20. doi: 10.1007/s12178-015-9278-7.
[5] Markel DC, Miskovsky C, Sculco TP, et al. (1996) Core decompression for osteonecrosis of the femoral head. Clin Orthop Relat Res 323:226–33
[6] Buckley PD, Gearen PF, Petty RW. (1991)Structural bone- grafting for early atraumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 73:1357–64.
[7] Ali SA, Christy JM, Griesser MJ, et al. (2014) Treatment of avas- cular necrosis of the femoral head utilising free vascularised fibular graft: a systematic review. Hip Int 24:5–13.
[8] Sorich MM, Cherian JJ, McElroy MJ et al. (2015) Osteonecrosis of the Hip in Hematologic Disease: A Review of Conditions and Treatment Options. J Long Term Eff Med Implants. 25(4):253-68.
[9] Trovato L, Monti M, Del Fante C, Cervio M, Lampinen M, Ambrosio L et al. (2015) A New Medical device rigeneracons allows to obtain viable micro-grafts from mechanical disaggregation of human tissues. J Cell Physiol 230:2299-303.
[10] Brunelli G, Motroni A, Graziano A, D'Aquino R, Zollino I, Carinci F. (2013) Sinus lift tissue engineering using autologous pulp micro-grafts: A case report of bone density evaluation. J Indian Soc Periodontol 17(5):644-7. doi: 10.4103/0972-124X.119284.
[11] Svolacchia F, De Francesco F, Trovato L, Graziano A, Ferraro GA. (2016) An innovative regenerative treatment of scars with dermal micrografts. J Cosmet Dermatol 15(3):245-53. doi: 10.1111/jocd.12212.
[12] Dawson J, Fitzpatrick R, Carr A, Murray D. (1996) Questionnaire on the perceptions of patients about total hip replacement. British Journal of Bone and Joint Surgery 78-B(2): 185-190.
[13] Gardeniers JWM. (1993) Report of the Committee of Staging and Nomenclature. ARCO News Letter, 5: n°2: 79-82.
[14] Marcarelli M, Trovato L, Novarese E, Riccio M, Graziano A. (2017) Rigenera protocol in the treatment of surgical wound dehiscence. Int Wound J 14(1):277-281. doi: 10.1111/iwj.12601.
[15] McGrory BJ, York SC, Iorio R, Macaulay W, Pelker RR, Parsley BS et al. (2007) Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head. J Bone Joint Surg Am 89:1194e204.
[16] Pierce TP, Jauregui JJ, Elmallah RK, Lavernia CJ, Mont MA, Nace J. (2015) A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 8:228e32. s12178-015-9280-0.
[17] De Francesco F, Graziano A, Trovato L, Ceccarelli G, Romano M, Marcarelli M, et al. (2017) A Regenerative Approach with Dermal Micrografts in the Treatment of Chronic Ulcers. Stem Cell Rev. 13(1):149. doi: 10.1007/s12015-016-9698-9
[18] Trovato L, Failla G, Serantoni S, Palumbo FP. (2016) Regenerative Surgery in the Management of the Leg Ulcers. J Cell Sci Ther 7:238. doi:10.4172/2157-7013.1000238
[19] Miranda R, Farina E, Farina MA. (2018) Micrografting chronic lower extremity ulcers with mechanically disaggregated skin using a micrograft preparation system. J Wound Care 27(2):60-65.

[20] Baglioni E, Trovato L, Marcarelli M, Frenello A, Bocchiotti MA. (2016) Treatment of Oncological Post-surgical Wound Dehiscence with Autologous Skin Micrografts. Anticancer Research 36(3): 975-980
[21] Ceccarelli G, Gentile P, Marcarelli M, Balli M, Ronzoni FL, Benedetti L et al. (2017) In Vitro and In Vivo Studies of Alar-Nasal Cartilage Using Autologous Micro-Grafts: The Use of the Rigenera® Protocol in the Treatment of an Osteochondral Lesion of the Nose. Pharmaceuticals (Basel) 10(2). pii: E53. doi: 10.3390/ph10020053
[22] Gentile P, Scioli MG, Bielli A, Orlandi A, Cervelli V. (2016) Reconstruction of Alar Nasal Cartilage Defects Using a Tissue Engineering Technique Based on a Combined Use of Autologous Chondrocyte Micrografts and Platelet-rich Plasma: Preliminary Clinical and Instrumental Evaluation. Plast Reconstr Surg Glob Open 4(10):e1027.
[23] Lampinen M, Nummi A, Nieminen T, Harjula A, Kankuri E. (2017) Intraoperative processing and epicardial transplantation of autologous atrial tissue for cardiac repair. Journal of Heart and Lung Transplantation 36(9), 1020-1022.
[24] Graziano A, Carinci F, Scolaro S, D’Aquino R. (2013) Periodontal tissue generation using autologous dental ligament micro-grafts: case report with 6 months follow-up. Annals of Oral & Maxillofacial Surgery 1(2):20
[25] Rodriguez y Baena, R., D'Aquino et al . (2017). Autologous periosteum-derived micrografts and PLGA/HA enhance the bone formation in sinus lift augmentation. Frontiers in cell and developmental biology, 5, 87.
[26] D’Aquino R, Trovato L, Graziano A, Ceccarelli G, Cusella de Angelis G, Marangini A et al. (2016) Periosteum-derived micro-grafts for tissue regeneration of human maxillary bone. Journal of Translational Science 2(2) 125-29 doi: 10.15761/JTS.1000128
[27] Makihara T, Yoshioka T, Sugaya H, Yamazaki M, Mishima H. (2017) Autologous Concentrated Bone Marrow Grafting for the Treatment of Osteonecrosis of the Humeral Head: A Report of Five Shoulders in Four Cases. Case Rep Orthop 2017:4898057. doi: 10.1155/2017/4898057.
[28] Zuo W, Sun W, Zhao D, Gao F, Su Y, Li Z. (2016) Investigating Clinical Failure of Bone Grafting through a Window at the Femoral Head Neck Junction Surgery for the Treatment of Osteonecrosis of the Femoral Head. PLoS One 11(6):e0156903. doi: 10.1371/journal.pone.0156903.
[29] Lee K, Chan CK, Patil N, Goodman SB. (2009) Cell therapy for bone regeneration—bench to bedside. J Biomed Mater Res B Appl Biomater. 89:252–263.
[30] Gangji V, Hauzeur JP, Schoutens A, Hinsenkamp M, Appelboom T, Egrise D. (2003) Abnormalities in the replicative capacity of osteoblastic cells in the proximal femur of patients with osteonecrosis of the femoral head. J Rheumatol. 30:348–351.

[31] Asada T, Kushida T, Umeda M, Oe K, Matsuya H, Wada T et al. (2008) Prevention of corticosteroid-induced osteonecrosis in rabbits by intra-bone marrow injection of autologous bone marrow cells. Rheumatology 47:591–596. doi: 10.1093/rheumatology/ken037.
[32] Yan Z, Hang D, Guo C, Chen Z. (2009) Fate of mesenchymal stem cells transplanted to osteonecrosis of femoral head. J Orthop Res. 27:442–446. doi: 10.1002/jor.20759
[33] Hernigou P, Beaujean F. (2002) Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res. 2002;405:14–23. doi: 10.1097/00003086-200212000-00003.
[34] Hernigou P, Poignard A, Zilber S, Rouard H. (2008) Cell therapy of hip osteonecrosis with autologous bone marrow grafting. Indian J Orthop. 43:40–45. doi: 10.4103/0019-5413.45322.
[35] Hernigou P, Zilber S, Filippini P, Rouard H, Mathieu G, Poignard A. (2008) Bone marrow injection in hip osteonecrosis. Tech Orthop. 23:18–25. doi: 10.1097/BTO.0b013e3181690814.
[36]Monti M, Graziano A, Rizzo S, Perotti C, Del Fante C, d'Aquino R et al. (2017) In Vitro and In Vivo Differentiation of Progenitor Stem Cells Obtained after Mechanical Digestion of Human Dental Pulp. J Cell Physiol. 232: 548–555. doi: 10.1002/jcp.25452
[37] Rohban R, Pieber TR. (2017) Mesenchymal Stem and Progenitor Cells in Regeneration: Tissue Specificity and Regenerative Potential. Stem Cells Int. 2017:5173732. doi: 10.1155/2017/5173732.
[38] Piuzzi NS, Chahla J, Jiandong H, Chughtai M, LaPrade RF, Mont MA et al. (2017) Analysis of Cell Therapies Used in Clinical Trials for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature. J Arthroplasty 32(8):2612-2618. doi: 10.1016/j.arth.2017.02.075.
[39] Piuzzi NS, Chahla J, Schrock J, , LaPrade RF, Pascual-Garrido C, Mont MA et al. (2017) Evidence for the use of cell-based therapy for the treatment of osteonecrosis of the femoral head: a systematic review of the literature. J Arthroplasty 32(5):1698-1708. doi: 10.1016/j.arth.2016.12.049

Most read articles by the same author(s)