Chinese Journal of Tissue Engineering Research ›› 2026, Vol. 30 ›› Issue (15): 3993-4009.doi: 10.12307/2026.738

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Network meta-analysis of core decompression combined with various therapies for early and mid-stage osteonecrosis of the femoral head

Guo Yuqi1, Li Jiacheng2, Lu Bowen1, Zhang Jiahao1, Li Gang2   

  1. 1First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan 250014, Shandong Province, China; 2Department of Orthopedics and Traumatology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250014, Shandong Province, China
  • Accepted:2025-07-09 Online:2026-05-28 Published:2025-11-10
  • Contact: Li Gang, MD, Professor, Chief physician, Doctoral supervisor, Department of Orthopedics and Traumatology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250014, Shandong Province, China
  • About author:Guo Yuqi, Master candidate, First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan 250014, Shandong Province, China
  • Supported by:
    Taishan Scholar Distinguished Expert (Selected in the Year 2025-Li Gang) Project, No. tsxztpzj-02 (to LG); Shandong Provincial Key Research & Development Program (Major Scientific and Technological Innovation Project), No. 2021CXGC010501 (to LG); Shandong Provincial Natural Science Foundation, No. ZR2022LZY003 (to LJC)

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Abstract: OBJECTIVE: To evaluate the efficacy and safety of core decompression combined with various therapeutic strategies in patients with early to mid-stage osteonecrosis of the femoral head.
METHODS: A systematic search was conducted in PubMed, Web of Science, Cochrane Library, EMbase, China National Knowledge Infrastructure, VIP, WanFang Data, and Chinese Biomedical Literature Service System for randomized controlled trials published up to January 19, 2025, on core decompression combined with different interventions for early to mid-stage osteonecrosis of the femoral head. The quality of the included studies was assessed using the Cochrane Risk of Bias Tool. The Grading of Recommendations Assessment, Development and Evaluation approach was applied to evaluate the quality of evidence. A Bayesian network meta-analysis model was constructed to synthesize the data. Effect sizes were estimated using standardized mean differences, and cumulative ranking probabilities were calculated to determine the relative effectiveness of each intervention. Sensitivity analyses were performed using the leave-one-out method, and the assumption of transitivity was examined based on baseline covariates.
RESULTS: A total of 73 randomized controlled trials involving 5 148 patients and 5 777 hips were included, covering 15 different combination therapies. The findings revealed that: (1) In terms of overall clinical efficacy, core decompression combined with bone marrow aspirate concentrate of mononuclear cells, bone marrow mesenchymal stem cell transplantation, structural bone grafting, or kidney-tonifying and blood-activating decoction was superior to core decompression alone, with the combination involving bone marrow aspirate concentrate of mononuclear cells demonstrating the best effect (the area under the cumulative ranking probability curve = 96.23%). (2) For hip function improvement, core decompression combined with staged Chinese medicine treatment showed the highest efficacy (the area under the cumulative ranking probability curve = 93.85%). (3) Regarding pain relief, combinations with compound proprietary medicine treatment (kidney-tonifying and blood-activating plus blood-activating and stasis-resolving) or blood-activating and stasis-resolving decoction exhibited prominent benefits. (4) For radiological improvements, core decompression combined with autologous stem cell implantation showed the best outcomes (the area under the cumulative ranking probability curve = 82.56%). (5) In terms of safety, core decompression combined with blood-activating and stasis-resolving decoction was associated with a relatively lower incidence of adverse events (P < 0.05). Sensitivity analysis using the leave-one-out method confirmed the robustness of the findings. The model remained stable across analyses, and the transitivity assumption was supported by baseline covariate assessment.
CONCLUSION: Core decompression combined with stem cell transplantation, Chinese medicine-based sequential therapies, and other combination strategies provides superior clinical outcomes compared with core decompression alone for patients with early to mid-stage osteonecrosis of the femoral head, particularly in terms of joint function preservation, structural restoration, and pain relief. Further high-quality, multicenter, large-sample randomized controlled trials are needed to confirm these findings due to limitations in sample size and methodological quality of some included studies.

Key words: core decompression, osteonecrosis of the femoral head, combination therapy, network meta-analysis, randomized controlled trial

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