Comparative Efficacy of Bone Defect Filler Strategies Following Lesion Debridement for Osteonecrosis of the Femoral Head: A Systematic Review and Network Meta‐Analysis

Abstract

ABSTRACT Objective This study aimed to systematically review and compare the clinical and radiographic outcomes of different bone defect filler materials following lesion debridement for osteonecrosis of the femoral head (ONFH). Existing evidence on filler materials relies heavily on isolated pairwise comparisons, leaving the optimal reconstruction strategy undefined. Therefore, the current network meta‐analysis integrates multiple treatments and diverse clinical endpoints to determine the most effective reconstructive option. With increasing recognition of the importance of intraosseous structural reconstruction, this study sought to provide evidence‐based guidance for filler selection in hip‐preserving treatment. Methods PubMed, MEDLINE, Embase, the Cochrane Library, Web of Science, and Scopus were searched from inception to March 2026. Comparative clinical studies evaluating two or more bone defect filler materials after lesion debridement for ONFH were included. Evidence was synthesized using a Bayesian random‐effects network meta‐analysis. Methodological quality and risk of bias were assessed using the Cochrane Risk of Bias Tool 2.0 for randomized controlled trials (RCTs) and a modified Newcastle–Ottawa Scale for non‐randomized comparative trials (NCTs). Results After screening 2046 records, 18 eligible studies were included, comprising 10 RCTs and 8 NCTs, with a total of 1176 patients and 1284 hips. Fourteen filler strategies were analyzed, including without graft, allograft, tantalum rods, iliac autograft, artificial bone, fibular autograft, vascularized iliac autograft, vascularized fibular autograft, artificial bone combined with iliac autograft, tantalum rods combined with autograft or allograft, other autografts, other autografts combined with vascularized greater trochanter graft, iliac autograft with screw fixation, and vascularized iliac autograft with screw fixation. Tantalum rods combined with bone graft showed relative advantages in functional recovery and pain relief, as assessed by the Harris Hip Score and Visual Analogue Scale. However, tantalum rods alone were associated with a higher rate of conversion to total hip arthroplasty. Allograft ranked favorably for early functional recovery and necrosis stage maintenance, although no significant differences were observed among interventions for necrosis stage maintenance. Iliac autograft with screw fixation ranked first in preventing radiographic progression. However, without significant pairwise differences, this ranking remains inconclusive. Conclusion Considering postoperative functional recovery, pain relief, and disease progression after lesion debridement, tantalum rods combined with bone graft may provide advantages in early outcomes, but the long‐term failure risk of tantalum rods alone should be carefully considered. Allograft and iliac autograft with screw fixation showed favorable profiles in specific outcome domains and may represent balanced options in selected patients. Further high‐quality studies with longer follow‐up are needed to validate the long‐term efficacy of different filler strategies.