Comparative efficacy and safety of core decompression, cell-based therapy, hyperbaric oxygen therapy, extracorporeal shock wave therapy, and combined regimens for osteonecrosis of the femoral head: a network meta-analysis.

Background: Osteonecrosis of the femoral head (ONFH) is a progressive, disabling disorder affecting young and middle-aged adults. Joint-preserving treatments-core decompression (CD), cell-based therapy, extracorporeal shock wave therapy (ESWT), hyperbaric oxygen therapy (HBO), and combined regimens-are increasingly used in early-to mid-stage ONFH, but their comparative efficacy and safety remain uncertain. Cellular therapies, varying in source, preparation, dose, and delivery, were analyzed as a single node to preserve network connectivity. Methods: This PRISMA-NMA-compliant network meta-analysis was prospectively registered in PROSPERO. PubMed, Embase, Web of Science, and Cochrane Library were searched through 20 April 2026. RCTs and retrospective comparative studies in adults with ONFH were eligible. Primary outcomes were visual analogue scale Harris Hip Score and imaging progression; secondary outcomes included total hip arthroplasty conversion, Oxford Hip Score SF-36, WOMAC, and adverse events. Random-effects models were used primarily, with fixed-effect models applied to sparse networks. Treatment rankings were estimated via SUCRA; risk of bias was assessed with RoB 2.0 and ROBINS-I. Results: Twenty-nine studies (2,177 hips) were included. HBO-based interventions, particularly HBO plus CD, showed the greatest pain reduction. CD plus ESWT ranked highest for HHS improvement, though substantial network inconsistency limited confidence in this ranking. For imaging progression, CD combined with cell therapy and ESWT significantly reduced radiographic deterioration, with CD plus cell therapy ranking highest. Heterogeneity in cell source, preparation, dose, and delivery precludes identification of an effective product or protocol. No intervention significantly reduced THA conversion. HBO plus CD ranked highest for OHS and SF-36, but these networks were sparse and estimates preliminary. ESWT showed the most favorable safety profile, although the safety endpoint combined events of markedly differing clinical severity. WOMAC results were highly heterogeneous and unstable in sensitivity analyses. Conclusion: Joint-preserving treatments for ONFH showed outcome-specific advantages rather than a uniform hierarchy. HBO-based therapy appeared most favorable for pain and quality of life, CD plus ESWT for function, and CD plus cell therapy or ESWT for structural preservation. The efficacy of specific cell products or protocols remains uncertain. High-quality randomized trials with standardized protocols, harmonized outcomes, and long-term follow-up are needed. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261379078, identifier PROSPERO CRD420261379078.