human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: What is the most effective treatment for the early stages of osteonecrosis of the femoral head ? We assessed multiple drilling and stem cell implantation to treat the early stages of osteonecrosis of the femoral head . We report the clinical and radiological results of stem cell implantation and core decompression . In total , 128 patients ( 190 hips ) who had undergone surgery were divided into two groups based on which treatment they had received : ( 1 ) multiple drilling and stem cell implantation or ( 2 ) core decompression , curettage and a bone graft . The clinical and radiographic results of the two groups were compared . At 5-year follow-up , in the stem cell implantation group , 64.3 % ( 27/42 ) of the patients with Stage IIa disease , 56.7 % ( 21/37 ) of the patients with Stage IIb disease and 42.9 % ( 21/49 ) of the patients with Stage III disease had undergone no additional surgery . In the conventional core decompression group , 64.3 % ( 9/14 ) of the patients with Stage IIa disease , 55.6 % ( 5/9 ) of the patients with Stage IIb disease and 37.5 % ( 3/8 ) of the patients with Stage III disease had undergone no additional surgery . Success rates were higher in patients with Ficat Stage I or II lesions than in those with Stage III lesions . There were no statistically significant differences between the groups in terms of success rate or in the clinical and radiographic results of the two methods . Essentially the same results were found with stem cell implantation  as with the conventional method of core decompression Introduction Avascular necrosis of femoral head ( ANFH ) is a progressive disease that often leads to hip joint dysfunction and even disability in young patients . Although the st and ard treatment , which is core decompression , has the advantage of minimal invasion , the efficacy is variable . Recent studies have shown that implantation of bone marrow containing osteogenic precursors into necrotic lesion of ANFH may be promising for the treatment of ANFH . Methods A prospect i ve , double-blinded , r and omized controlled trial was conducted to examine the effect of bone-marrow buffy coat ( BBC ) grafting combined with core decompression for the treatment of ANFH . Forty-five patients ( 53 hips ) with Ficat stage I to III ANFH were recruited . The hips were allocated to the control group ( core decompression + autologous bone graft ) or treatment group ( core decompression + autologous bone graft with BBC ) . Both patients and assessors were blinded to the treatment options . The clinical symptoms and disease progression were assessed as the primary and secondary outcomes . Results At the final follow-up ( 24 months ) , there was a significant relief in pain ( P < 0.05 ) and clinical joint symptoms as measured by the Lequesne index ( P < 0.05 ) and Western Ontario and McMaster Universities Arthritis Index ( P < 0.05 ) in the treatment group . In addition , 33.3 % of the hips in the control group have deteriorated to the next stage after 24 months post-procedure , whereas only 8 % in the treatment group had further deterioration ( P < 0.05 ) . More importantly , the non-progression rates for stage I/II hips were 100 % in the treatment group and 66.7 % in the control group . Conclusion Implantation of the autologous BBC grafting combined with core decompression is effective to prevent further progression for the early stages of ANFH.Trial registration Clinical Trials.gov identifier NCT01613612 . Registered 13 December 2011 The management of early-stage osteonecrosis of the femoral head ( ONFH ) remains challenging . This study aim ed to evaluate the effects of core decompression and concentrated bone marrow implantation on ONFH . The study recruited 28 hips with early ONFH r and omly assigned into two groups of core decompression with ( group A ) and without ( group B ) bone marrow injection . Patients were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) question naire , Visual Analogue Scale ( VAS ) pain index , and MRI . The mean WOMAC and VAS scores in all patients improved significantly ( P<0.001 ) . MRI showed a significant improvement in group A ( P=0.046 ) and significant worsening in group B ( P<0.001 ) . Bone marrow stem cell injection with core decompression can be effective in early ONFH The aim of this study was to investigate the safety of injection of bone marrow aspirate concentrate during core decompression and to study its clinical ( visual analogue scale ; Harris-Hip-score ) and radiological outcomes ( magnetic resonance imaging ) . In this prospect i ve and r and omized clinical trial we evaluated 24 consecutive patients with non-traumatic femoral head necrosis ( FHN ) during a period of two years after intervention . In vitro analysis of mesenchymal stem cells was performed by evaluating the fibroblast colony forming units ( CFU-Fs ) . Postoperatively , significant decrease in pain associated with a functional benefit lasting was observed . However , there was no difference in the clinical outcome between the two study groups . Over the period of two years there was no significant difference between the head survival rate between both groups . In contrast to that , we could not perceive any significant change in the volume of FHN in both treatment groups related to the longitudinal course after treating . The number of CFU showed a significant increase after centrifugation . This trial could not detect a benefit from the additional injection of bone marrow concentrate with regard to bone regeneration and clinical outcome in the short term Fifty-one osteonecrotic hips in 40 patients were r and omly divided into 2 treatment groups . Patients in group A ( 25 hips ) were treated with core decompression , and those in group B ( 26 hips ) received autologous bone marrow mononuclear cell instillation into the core tract after core decompression . Outcome between the 2 groups were compared clinical ly ( Harris Hip score ) , radiographically ( x-ray and magnetic resonance imaging ) , and by Kaplan-Meier hip survival analysis after 12 and 24 months of surgical intervention . The clinical score and mean hip survival were significantly better in group B than in group A ( P < .05 ) . Patients with adverse prognostic features at initial presentation , that is , poor Harris Hip score , x-ray changes , edema , and /or effusion on magnetic resonance imaging had significantly better clinical outcome and hip survival in group B than in group BACKGROUND Treatment of early-stage osteonecrosis of the femoral head ( ONFH ) with autologous implantation of iliac crest bone marrow-derived mononuclear cells , which contain tens of thous and s of bone marrow mesenchymal stem cells ( BMMSCs ) , recently achieved a promising outcome . METHODS One hundred patients with early-stage ONFH were recruited and r and omly assigned to BMMSC treatment or core decompression ( CD ) treatment . Each BMMSC-treated hip received femoral head ( FH ) implantation of 2 × 10(6 ) autologous subtrochanteric bone marrow-derived and ex vivo exp and ed BMMSCs . The radiographic stage of ONFH according to the Association Research Circulation Osseous classification , Harris hip score ( HHS ) , and the volume of the necrotic lesion or the low signal intensity zone ( LowSIZ ) in the FH were assessed before and 6 , 12 , 24 , and 60 months after the initial operation . RESULTS Sixty months after the operation , only 2 of the 53 BMMSC-treated hips progressed and underwent vascularized bone grafting . In CD group , 7 hips lost follow-up , and 10 of the rest 44 hips progressed and underwent  vascularized bone grafting  ( 5 hips ) or total hip replacement ( 5 hips ) . Compared with the CD group , BMMSC treatment significantly improved the HHS as well as decreased the volume of femoral head LowSIZ of the hips preoperatively classified at stage IC , IIB , and IIC ( P<0.05 , respectively ; stage IIA , P=0.06 , respectively ) . No complication was observed in both treatment groups . CONCLUSIONS Ex vivo expansion of autologous BMMSCs can reliably provide a greater number of BMMSCs for FH implantation . This intervention is safe and effective in delaying or avoiding FH collapse , which may necessitate total hip replacement The review describes the following : ( 1 ) how traditional core decompression is performed , ( 2 ) adjunctive treatments , ( 3 ) multiple percutaneous drilling technique , and ( 4 ) the overall outcomes of these procedures . Core decompression has optimal outcomes when used in the earliest , precollapse disease stages . More recent studies have reported excellent outcomes with percutaneous drilling . Furthermore , adjunct treatment methods combining core decompression with growth factors , bone morphogenic proteins , stem cells , and bone grafting have demonstrated positive results ; however , larger r and omized trial is needed to evaluate their overall efficacy The bone-marrow activity in the iliac crest of eleven patients who had idiopathic osteonecrosis of the hip and thirty patients who had osteonecrosis of the hip that was related to corticosteroid therapy ( fourteen patients ) or to alcohol abuse ( sixteen patients ) was compared with that in two groups of control subjects who did not have osteonecrosis ( thirty-three healthy bone-marrow donors and thirty-four patients who had been managed with bone-marrow grafting for a non-union ) . Cultures of granulocyte-macrophage progenitor cells and fibroblast colony-forming units were performed to assess the activity of hematopoietic stem cells and stromal cells . The activity of stem cells in both the hematopoietic and the stromal compartment of the bone marrow was decreased in the patients who were receiving corticosteroids or who abused alcohol , as compared with that in the two groups of control subjects . The patients who had idiopathic osteonecrosis also had a decrease in bone-marrow activity compared with the control subjects . CLINICAL RELEVANCE : Our findings suggest that patients who are receiving corticosteroid therapy or who abuse alcohol have decreased activity of bone-marrow cells . Whether this decrease is related to the osteonecrosis could not be determined , as our study did not include control subjects who had a history of alcohol abuse or who were receiving corticosteroids  but did not have osteonecrosis . However , it is possible that the reduced bone-marrow activity was related to the osteonecrosis , as patients who had idiopathic osteonecrosis also had decreased bone-marrow activity . The study of pathological alterations in the bone marrow outside the necrotic zone may provide important insights into the pathophysiology of osteonecrosis Core decompression with bone graft is used frequently in the treatment of osteonecrosis of the femoral head . Many different techniques have been described . In the current series , grafting was done with autologous bone marrow obtained from the iliac crest of patients operated on for osteonecrosis of the hip . The results of a prospect i ve study of 189 hips in 116 patients treated with core decompression and autologous bone marrow grafting are reported . Patients were followed up from 5 to 10 years . The outcome was determined by the changes in the Harris hip score , by progression in radiographic stages , and by the need for hip replacement . The bone marrow was harvested with the patient under general anesthesia . The usual sites were the anterior iliac crests . The aspirated marrow was reduced in volume by concentration and injected into the femoral head after core decompression with a small trocar . When patients were operated on before collapse ( Stage I and Stage II ) , hip replacement was done in nine of the 145 hips . Total hip replacement was necessary in 25 hips among the 44 hips operated on after collapse ( Stage III and Stage IV ) . To measure the number of progenitor cells transplanted , the fibroblast colony forming unit was used as an indicator of the stroma cell activity . Patients who had the greater number of progenitor cells transplanted in their hips had better outcomes The objective of this study was to determine the benefits of combination treatment with mechanical support and targeted intra-arterial infusion of peripheral blood stem cells ( PBSCs ) mobilized by granulocyte-colony stimulating factor ( G-CSF ) via the medial circumflex femoral artery on the progression of osteonecrosis of the femoral head ( ONFH ) . Fifty-five patients ( 89 hips ) with early and intermediate stage ONFH were recruited and r and omly assigned to combination treatment or mechanical support treatment ( control group ) . All hips received mechanical support treatment ( porous tantalum rod implantation ) . Then , hips in the combination treatment group were performed targeted intra-arterial infusion of PBSCs . At each follow-up , Harris hip score ( HHS ) and Association Research Circulation Osseous ( ARCO ) classification were used to evaluate the symptoms and progression of osteonecrosis . Total hip arthroplasty ( THA ) was assessed as an endpoint at each follow-up . At 36 months , 9 of the 41 hips ( 21.95 % ) in the control group progressed to clinical failure and underwent THA whereas only 3 of the 48 hips ( 6.25 % ) in the combination treatment group required THA ( p = 0.031 ) . Kaplan-Meier survival analysis showed a significant difference in the survival time between the two groups ( log-rank test ; p = 0.025 ) . Compared to the control group , combination treatment significantly improved the HHS at 36 months ( p = 0.003 ) . At the final follow-up examination , radiological progression was noted in 1 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: What is the most effective treatment for the early stages of osteonecrosis of the femoral head ? We assessed multiple drilling and stem cell implantation to treat the early stages of osteonecrosis of the femoral head . We report the clinical and radiological results of stem cell implantation and core decompression . In total , 128 patients ( 190 hips ) who had undergone surgery were divided into two groups based on which treatment they had received : ( 1 ) multiple drilling and stem cell implantation or ( 2 ) core decompression , curettage and a bone graft . The clinical and radiographic results of the two groups were compared . At 5-year follow-up , in the stem cell implantation group , 64.3 % ( 27/42 ) of the patients with Stage IIa disease , 56.7 % ( 21/37 ) of the patients with Stage IIb disease and 42.9 % ( 21/49 ) of the patients with Stage III disease had undergone no additional surgery . In the conventional core decompression group , 64.3 % ( 9/14 ) of the patients with Stage IIa disease , 55.6 % ( 5/9 ) of the patients with Stage IIb disease and 37.5 % ( 3/8 ) of the patients with Stage III disease had undergone no additional surgery . Success rates were higher in patients with Ficat Stage I or II lesions than in those with Stage III lesions . There were no statistically significant differences between the groups in terms of success rate or in the clinical and radiographic results of the two methods . Essentially the same results were found with stem cell implantation  as with the conventional method of core decompression Introduction Avascular necrosis of femoral head ( ANFH ) is a progressive disease that often leads to hip joint dysfunction and even disability in young patients . Although the st and ard treatment , which is core decompression , has the advantage of minimal invasion , the efficacy is variable . Recent studies have shown that implantation of bone marrow containing osteogenic precursors into necrotic lesion of ANFH may be promising for the treatment of ANFH . Methods A prospect i ve , double-blinded , r and omized controlled trial was conducted to examine the effect of bone-marrow buffy coat ( BBC ) grafting combined with core decompression for the treatment of ANFH . Forty-five patients ( 53 hips ) with Ficat stage I to III ANFH were recruited . The hips were allocated to the control group ( core decompression + autologous bone graft ) or treatment group ( core decompression + autologous bone graft with BBC ) . Both patients and assessors were blinded to the treatment options . The clinical symptoms and disease progression were assessed as the primary and secondary outcomes . Results At the final follow-up ( 24 months ) , there was a significant relief in pain ( P < 0.05 ) and clinical joint symptoms as measured by the Lequesne index ( P < 0.05 ) and Western Ontario and McMaster Universities Arthritis Index ( P < 0.05 ) in the treatment group . In addition , 33.3 % of the hips in the control group have deteriorated to the next stage after 24 months post-procedure , whereas only 8 % in the treatment group had further deterioration ( P < 0.05 ) . More importantly , the non-progression rates for stage I/II hips were 100 % in the treatment group and 66.7 % in the control group . Conclusion Implantation of the autologous BBC grafting combined with core decompression is effective to prevent further progression for the early stages of ANFH.Trial registration Clinical Trials.gov identifier NCT01613612 . Registered 13 December 2011 The management of early-stage osteonecrosis of the femoral head ( ONFH ) remains challenging . This study aim ed to evaluate the effects of core decompression and concentrated bone marrow implantation on ONFH . The study recruited 28 hips with early ONFH r and omly assigned into two groups of core decompression with ( group A ) and without ( group B ) bone marrow injection . Patients were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) question naire , Visual Analogue Scale ( VAS ) pain index , and MRI . The mean WOMAC and VAS scores in all patients improved significantly ( P<0.001 ) . MRI showed a significant improvement in group A ( P=0.046 ) and significant worsening in group B ( P<0.001 ) . Bone marrow stem cell injection with core decompression can be effective in early ONFH The aim of this study was to investigate the safety of injection of bone marrow aspirate concentrate during core decompression and to study its clinical ( visual analogue scale ; Harris-Hip-score ) and radiological outcomes ( magnetic resonance imaging ) . In this prospect i ve and r and omized clinical trial we evaluated 24 consecutive patients with non-traumatic femoral head necrosis ( FHN ) during a period of two years after intervention . In vitro analysis of mesenchymal stem cells was performed by evaluating the fibroblast colony forming units ( CFU-Fs ) . Postoperatively , significant decrease in pain associated with a functional benefit lasting was observed . However , there was no difference in the clinical outcome between the two study groups . Over the period of two years there was no significant difference between the head survival rate between both groups . In contrast to that , we could not perceive any significant change in the volume of FHN in both treatment groups related to the longitudinal course after treating . The number of CFU showed a significant increase after centrifugation . This trial could not detect a benefit from the additional injection of bone marrow concentrate with regard to bone regeneration and clinical outcome in the short term Fifty-one osteonecrotic hips in 40 patients were r and omly divided into 2 treatment groups . Patients in group A ( 25 hips ) were treated with core decompression , and those in group B ( 26 hips ) received autologous bone marrow mononuclear cell instillation into the core tract after core decompression . Outcome between the 2 groups were compared clinical ly ( Harris Hip score ) , radiographically ( x-ray and magnetic resonance imaging ) , and by Kaplan-Meier hip survival analysis after 12 and 24 months of surgical intervention . The clinical score and mean hip survival were significantly better in group B than in group A ( P < .05 ) . Patients with adverse prognostic features at initial presentation , that is , poor Harris Hip score , x-ray changes , edema , and /or effusion on magnetic resonance imaging had significantly better clinical outcome and hip survival in group B than in group BACKGROUND Treatment of early-stage osteonecrosis of the femoral head ( ONFH ) with autologous implantation of iliac crest bone marrow-derived mononuclear cells , which contain tens of thous and s of bone marrow mesenchymal stem cells ( BMMSCs ) , recently achieved a promising outcome . METHODS One hundred patients with early-stage ONFH were recruited and r and omly assigned to BMMSC treatment or core decompression ( CD ) treatment . Each BMMSC-treated hip received femoral head ( FH ) implantation of 2 × 10(6 ) autologous subtrochanteric bone marrow-derived and ex vivo exp and ed BMMSCs . The radiographic stage of ONFH according to the Association Research Circulation Osseous classification , Harris hip score ( HHS ) , and the volume of the necrotic lesion or the low signal intensity zone ( LowSIZ ) in the FH were assessed before and 6 , 12 , 24 , and 60 months after the initial operation . RESULTS Sixty months after the operation , only 2 of the 53 BMMSC-treated hips progressed and underwent vascularized bone grafting . In CD group , 7 hips lost follow-up , and 10 of the rest 44 hips progressed and underwent  vascularized bone grafting  ( 5 hips ) or total hip replacement ( 5 hips ) . Compared with the CD group , BMMSC treatment significantly improved the HHS as well as decreased the volume of femoral head LowSIZ of the hips preoperatively classified at stage IC , IIB , and IIC ( P<0.05 , respectively ; stage IIA , P=0.06 , respectively ) . No complication was observed in both treatment groups . CONCLUSIONS Ex vivo expansion of autologous BMMSCs can reliably provide a greater number of BMMSCs for FH implantation . This intervention is safe and effective in delaying or avoiding FH collapse , which may necessitate total hip replacement The review describes the following : ( 1 ) how traditional core decompression is performed , ( 2 ) adjunctive treatments , ( 3 ) multiple percutaneous drilling technique , and ( 4 ) the overall outcomes of these procedures . Core decompression has optimal outcomes when used in the earliest , precollapse disease stages . More recent studies have reported excellent outcomes with percutaneous drilling . Furthermore , adjunct treatment methods combining core decompression with growth factors , bone morphogenic proteins , stem cells , and bone grafting have demonstrated positive results ; however , larger r and omized trial is needed to evaluate their overall efficacy The bone-marrow activity in the iliac crest of eleven patients who had idiopathic osteonecrosis of the hip and thirty patients who had osteonecrosis of the hip that was related to corticosteroid therapy ( fourteen patients ) or to alcohol abuse ( sixteen patients ) was compared with that in two groups of control subjects who did not have osteonecrosis ( thirty-three healthy bone-marrow donors and thirty-four patients who had been managed with bone-marrow grafting for a non-union ) . Cultures of granulocyte-macrophage progenitor cells and fibroblast colony-forming units were performed to assess the activity of hematopoietic stem cells and stromal cells . The activity of stem cells in both the hematopoietic and the stromal compartment of the bone marrow was decreased in the patients who were receiving corticosteroids or who abused alcohol , as compared with that in the two groups of control subjects . The patients who had idiopathic osteonecrosis also had a decrease in bone-marrow activity compared with the control subjects . CLINICAL RELEVANCE : Our findings suggest that patients who are receiving corticosteroid therapy or who abuse alcohol have decreased activity of bone-marrow cells . Whether this decrease is related to the osteonecrosis could not be determined , as our study did not include control subjects who had a history of alcohol abuse or who were receiving corticosteroids  but did not have osteonecrosis . However , it is possible that the reduced bone-marrow activity was related to the osteonecrosis , as patients who had idiopathic osteonecrosis also had decreased bone-marrow activity . The study of pathological alterations in the bone marrow outside the necrotic zone may provide important insights into the pathophysiology of osteonecrosis Core decompression with bone graft is used frequently in the treatment of osteonecrosis of the femoral head . Many different techniques have been described . In the current series , grafting was done with autologous bone marrow obtained from the iliac crest of patients operated on for osteonecrosis of the hip . The results of a prospect i ve study of 189 hips in 116 patients treated with core decompression and autologous bone marrow grafting are reported . Patients were followed up from 5 to 10 years . The outcome was determined by the changes in the Harris hip score , by progression in radiographic stages , and by the need for hip replacement . The bone marrow was harvested with the patient under general anesthesia . The usual sites were the anterior iliac crests . The aspirated marrow was reduced in volume by concentration and injected into the femoral head after core decompression with a small trocar . When patients were operated on before collapse ( Stage I and Stage II ) , hip replacement was done in nine of the 145 hips . Total hip replacement was necessary in 25 hips among the 44 hips operated on after collapse ( Stage III and Stage IV ) . To measure the number of progenitor cells transplanted , the fibroblast colony forming unit was used as an indicator of the stroma cell activity . Patients who had the greater number of progenitor cells transplanted in their hips had better outcomes The objective of this study was to determine the benefits of combination treatment with mechanical support and targeted intra-arterial infusion of peripheral blood stem cells ( PBSCs ) mobilized by granulocyte-colony stimulating factor ( G-CSF ) via the medial circumflex femoral artery on the progression of osteonecrosis of the femoral head ( ONFH ) . Fifty-five patients ( 89 hips ) with early and intermediate stage ONFH were recruited and r and omly assigned to combination treatment or mechanical support treatment ( control group ) . All hips received mechanical support treatment ( porous tantalum rod implantation ) . Then , hips in the combination treatment group were performed targeted intra-arterial infusion of PBSCs . At each follow-up , Harris hip score ( HHS ) and Association Research Circulation Osseous ( ARCO ) classification were used to evaluate the symptoms and progression of osteonecrosis . Total hip arthroplasty ( THA ) was assessed as an endpoint at each follow-up . At 36 months , 9 of the 41 hips ( 21.95 % ) in the control group progressed to clinical failure and underwent THA whereas only 3 of the 48 hips ( 6.25 % ) in the combination treatment group required THA ( p = 0.031 ) . Kaplan-Meier survival analysis showed a significant difference in the survival time between the two groups ( log-rank test ; p = 0.025 ) . Compared to the control group , combination treatment significantly improved the HHS at 36 months ( p = 0.003 ) . At the final follow-up examination , radiological progression was noted in 1 
    Output:
    