Evaluation of core decompression outcome in systemic lupus erythematosus with hip osteonecrosis: a retrospective cohort study

Abstract Background Osteonecrosis is a major cause of morbidity for patients with systemic lupus erythematosus (SLE). Although core decompression is an approved and trusted technique to prevent further joint deterioration, this surgical method seems to be less beneficial for SLE patients. We aimed to evaluate the outcomes of core decompression in SLE patients with primary stages of femoral head osteonecrosis. Methods In this study, 23 patients (39 affected hip joints) with osteonecrosis of the femoral head with stage II of the disease, based on the Ficat-Arlet classification system, underwent core decompression. Also, patients demographic characteristics, clinical data, medication history, comorbidities, immunological findings, hip plain radiographs, history of total hip arthroplasty after core decompression, and patients satisfaction with joint function according to the Oxford hip score questionnaire were obtained. Results In the study, 53.8% of affected joints showed signs of radiographic deterioration in follow-up imaging. Sixty-one and a half percent (61.5%) of patients had unsatisfactory joint performance. A third (33.3%) of affected hip joints underwent total hip arthroplasty up to 5 years from core decompression. SLE patients with a history of receiving bisphosphonate were 83.2% less dissatisfied with their joint function than patients without a history of bisphospho-nate use (P < 0.02). Of the 23 studied cases, the mean cumulative dose of prednisolone before and after core decompression surgery was 46.41 mg and 14.74 mg respectively. Besides, one case (2.6%) that had a high anti-phospholipid antibodies level during follow-up did not have any radiographic deterioration, and 9 cases (23.1%) had some degrees of radiographic deterioration. Conclusions The patients group that used bis-phosphonate, had a higher level of satisfaction with joint function after core decompression. Patients with high-level anti-phospholipid antibodies are related to a poor prognosis after core decompression.

A rare case of avascular necrosis of the hip joint secondary to ochronosis

This is a case report of a 53-year-old female patient who presented with long-standing hip pain secondary to avascular necrosis of the hip joint. She underwent total hip replacement and her intraoperative findings raised suspicion of ochronosis and was retrospectively evaluated for alkaptonuria both clinically and through biochemical investigations to confirm the diagnosis

Effectiveness of platelet-rich plasma as an adjunct to core decompression to treatment outcomes and femoral head preservation in avascular necrosis of the hip: A meta-analysis of randomized controlled trials

Background@#Avascular necrosis (AVN) of the femoral head results from intraosseous pathology causing functional impairment. Early diagnosis allows conservative treatment like core decompression, delaying total hip arthroplasty.@*Objective@#This meta-analysis aims to summarize platelet-rich plasma's (PRP) impact as an adjunct to core decompression (CD) on treatment outcomes and femoral head preservation in hip AVN. @*Methods@#The study conducted a comprehensive literature search using PubMed, Cochrane Library, Science Direct, Google Scholar and Med Line, including randomized controlled trials (RCTs) and previous meta-analyses from various databases. Using a random effects model, it compared PRP+CD with bone grafting to CD with bone grafting alone in AVN patients, evaluating function, pain scores, disease progression and the need for hip surgery.@*Results@#The meta-analysis examined 1041 records and included three studies. The primary outcomes were function and pain scores using Harris Hip Scoring (HHS) and Visual Analog Scale (VAS). Postoperative HHS scores at final follow-up favored the PRP+CD group significantly over CD alone. Postoperative VAS scores showed a trend towards higher scores in the CD alone group. The PRP+CD group demonstrated higher survival from disease progression compared to CD alone. Overall, the study suggests that PRP+CD led to better functional outcomes and disease progression outcomes than CD alone in AVN of the hip.@*Conclusion@#The PRP+CD treatment group showed significant benefits in AVN patients compared to CD alone, including higher HHS scores, improved disease progression survival and reduced need for hip surgery. Although PRP+CD resulted in decreased VAS scores, the difference was not statistically significant.

Kummel's disease

Kummel's disease is a crush fracture of a vertebral body caused by a minor trauma, with the most accepted etiology being avascular necrosis. It is more frequent in individuals with risk factors such as osteoporosis or prolonged treatment with corticosteroids. Initially, it usually has normal radiological tests and an asymptomatic period, followed by a progressive onset of pain along with probable kyphosis and a sign of void or fluid abscess on radiological tests, which may create nerve/spinal involvement. The case is presented of a 76-year-old man, who was admitted to this center for the differential diagnosis of a single vertebral lesion. After imaging tests and biopsy, the definitive diagnosis of Kummel's disease was reached. The confirmatory diagnosis was reached by vertebral biopsy, but given its invasive nature, imaging techniques can play a significant role. As regards metabolic imaging tests, bone scintigraphy has shown to be one of the most sensitive tools to detect ischemia in earlier stages or to determine if it affects other locations. The whole body scan with diphosphonates shows an increase in activity in relation to bone remodeling activity in this condition. The 3-phase study makes it possible to differentiate whether it is an acute/subacute or chronic process, and can influence the therapeutic decision. Knowledge of this disease is important to make a differential diagnosis with tumour or infectious pathology, with emphasis on performing imaging tests in the event of persistent pain with a normal initial plaque.

La enfermedad de Kummel es una fractura-aplastamiento de un cuerpo vertebral precedida por un traumatismo menor, cuya etiología más aceptada es la necrosis avascular. Es más frecuente en individuos con factores de riesgo como osteoporosis o tratamiento prolongado con corticoides. Inicialmente, suele presentar pruebas radiológicas normales y un periodo asintomático, con aparición progresiva del dolor junto a probable cifosis y signo del vacío o absceso líquido en las pruebas radiológicas, pudiendo llegar a crear compromiso nervioso/medular. Presentamos el caso de un varón de 76 arios que ingresa en nuestro centro para el diagnóstico diferencial de una lesión única vertebral; tras la realización de las pruebas de imagen y biopsia se llega al diagnóstico definitivo de enfermedad de Kummel. El diagnóstico de confirmación de esta enfermedad se alcanza mediante la biopsia vertebral, pero dada su naturaleza invasiva, las técnicas de imagen toman un papel relevante. En relación con las pruebas de imagen metabólicas, la gammagrafía ósea ha demostrado ser una de las herramientas más sensibles para detectar isquemia en fases más tempranas o para conocer si afecta a otras localizaciones. El rastreo corporal de cuerpo completo con difosfonatos muestra un aumento de actividad en relación con la actividad ósea remodelativa en este cuadro. El estudio de tres fases permite diferenciar si se trata de un proceso agudo/subagudo o crónico, lo que influye en la decisión terapéutica. Es importante el conocimiento de esta enfermedad para realizar diagnóstico diferencial con patología tumoral o infecciosa e insistir en la realización de pruebas de imagen ante la persistencia del dolor con una placa inicial normal.

A rare case of osteonecrosis of hip in sickle cell disease

Avascular necrosis of bone is a severe complication of sickle cell disease (SCD) and Management of these problems is often difficult because of the diagnostic imprecision of most laboratory and imaging investigations and because of the lack of evidence for most surgical procedures in sickle cell disease. Its treatment is not standardized. The objective in this case is to determine the impact of core decompression and PRP infusion in the management of Avascular necrosis of hip. In this case, a young Indian male with a known history of sickle cell disease presented to the clinic with severe bilateral hip pain. The pain had lasted for several months and had not improved with anti- inflammatory medication and starting on alandronate. There was severe pain with internal and external rotation of the hip. MRI of the femur showed stage 2 or 3 avascular necrosis of the femoral head, while X-rays of the femur were unremarkable. Patient managed conservatively by Non weight- bearing for several weeks and oral medication shortly thereafter, the patient underwent core decompression of the bilateral femoral head as well as continuing on Alendronate, a bisphosphonate. The patient improved temporarily but regressed shortly thereafter. His avascular necrosis worsened radiographically over the next several months. At this point, the only other option would be to do a total hip arthroplasty, but the patient may need several more throughout his lifetime due to the lifespan of the artificial replacement. There have only been scarce reports of avascular necrosis in patients with sickle cell trait. This manuscript presents such a case and includes the trials and tribulations associated with its management.

Research progress on the relationship between steroid-induced avascular necrosis of the femoral head and microRNA / 中国医师杂志

Steroid-induced avascular necrosis of the femoral head (SANFH) is the death of the femoral head caused by long-term use of glucocorticoid (GC). Its pathological manifestations are mainly trabecular bone collapse and increased empty bone lacunas, osteocyte apoptosis rate and autophagy rate. Its pathogenesis is complicated, and the exact pathogenesis is still unclear. MicroRNAs (miRNAs) are a group of endogenous, non-coding small RNAs with an average length of 23 nucleotides. They are responsible for negatively regulating gene expression after transcription by inhibiting target messenger RNAs (mRNAs). MiRNAs play an important role in physiological processes, including cell development, proliferation, differentiation, metabolism, migration and apoptosis. According to bioinformatics analysis, MiRNAs play an important role in regulating gene expression, and it is estimated that more than one-third of human genes are regulated by them. In the past few years, more and more miRNAs have been found to be related to osteonecrosis, such as regulating the proliferation and differentiation of mesenchymal stem cells and osteoblasts. This article aims to review the relationship between steroid-induced femoral head necrosis and miRNAs.

Degradable high purity magnesium screw in fixing the greater trochanter bone flap pedicled with transverse branch of lateral circumflex femoral artery: Treatment of avascular necrosis of femoral head in 12 young and middle-aged patients / 中华显微外科杂志

Objective:To investigate the effect of a degradable high-purity magnesium screw in fixing the greater trochanter bone flap of a lateral circumflex femoral artery transverse branch in the treatment of ischemic necrosis of femoral head in young and middle-aged adults.Methods:From February 2017 to February 2019, 12 cases (15 hips) of young and middle-aged patients with avascular necrosis of femoral head were treated in the Department of Orthopaedic of Affiliated Zhongshan Hospital of Dalian University. The age of patients was 30-53 years old. According to Association Research Circulation Osseous (ARCO), 2 hips were graded in stage II b, 4 in ARCO II c, 1 in ARCO III a, 5 in ARCO III b, 2 in ARCO III c and 1 in ARCO IV. The greater trochanter bone flap with a lateral circumferential vascular branch was used to fill the necrotic area, and fixed by a biodegradable high purity magnesium screw in the bone flap transfer. At 3, 6 and 12 months postoperation, the patient came to the hospital outpatient clinic for follow-up, and then were reviewed once a year. Imaging efficacy was evaluated by comparing preoperative and postoperative imaging. The Harris score and Visual Anoalogue Scale (VAS) score were tested at 12 and 24 months after surgery. The Harris score and VAS score before and after surgery were compared by Friedman test, and P<0.05 was considered statistically significant. Results:All 12 patients (15 hips) were entered in the 24-36 months of follow-up. At 12 and 24 months after surgery, Harris score was found at 87 (86, 92) and 90 (87, 92) respertively, which were both higher than that before surgery [59 (52, 74)] with a significant statistical difference ( Z=-3.743, Z=-4.473, P<0.05). However, there was no significant difference in Harris scores between 12 and 24 months after the surgery ( Z=-0.730, P>0.05). At the 12 and 24 months after surgery, VAS score was found at 3 (2, 3) and 2 (1, 3) respertively, which were both lower than that before surgery [6 (5, 6) ] with a significant statistical difference ( Z=-3.560, Z=-4.656, P<0.05). There was no statistical difference in VAS scores between 12 and 24 months after surgery ( Z=-1.095, P>0.05). X-ray and CT scan showed that the bone flaps healed well and the areas of osteonecrosis were repaired. Thirteen femoral heads were in good shape, and 2 femoral heads had further collapse of hips. No patients underwent joint replacement surgery at the time of last follow-up. Conclusion:Fixation of the greater trochanter flap of lateral circumflex femoral artery transverse branch with a degradable high-purity magnesium screw can ensure the healing of the flap at the implantation site and avoid the displacement and shedding of the flap. It is a new therapeutic option to treat the avascular necrosis of femoral head of young and middle-aged people.

Polymorphisms and avascular necrosis in patients with sickle cell disease - A systematic review / Polimorfismos e necrose avascular em pacientes com doença falciforme - Uma revisão sistemática

Abstract Objective: To systematically establish whether there is an association between polymorphisms and avascular necrosis in patients with sickle cell disease. Data source: The review, conducted according to PRISMA guidelines and registered with PROSPERO, was based on research of studies in PubMed, SciELO, LILACS, BVS databases and in the gray literature (Google Scholar and Open Gray) published until June 2020. The STROBE initiative was used to analyze the articles' quality. Data synthesis: Ten articles were selected from the databases and two were included through manual search, totaling 12 studies. All samples gathered 2,362 patients. According to STROBE, seven studies fully and/or partially covered more than 70% of the essential items and two studies reached less than 60%, with an overall variation of 86.4-54.5%. The results indicate that polymorphisms in the genes of the bone morphogenetic protein 6 (BMP6), Klotho (KL) and Annexin A2 (ANXA2) may be associated with osteonecrosis in the context of sickle cell disease. Six articles addressed the polymorphism in the MTHFR enzyme gene, but only one found a positive association. Polymorphisms associated with the DARC receptor, the ITGA4 gene, CD36 and thrombophilia protein genes were not associated in any of the studies. Conclusions: The results indicate that the polymorphisms in BMP6, Klotho and ANXA2 genes may be associated with avascular necrosis in patients with sickle cell disease. However, in order to confirm these genetic changes as risk factors, further studies with greater statistical power and methodological rigor are needed.

Resumo Objetivo: Estabelecer, de modo sistemático, se existe associação entre polimorfismos e a necrose avascular em pacientes com doença falciforme. Fontes de dados: A revisão, conduzida segundo as diretrizes Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) e registrada no International Prospective Register of Systematic Reviews (PROSPERO), foi baseada na busca de estudos nas bases de dados PubMed, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Biblioteca Virtual em Saúde (BVS) e na literatura cinza (Google Scholar e Open Gray) até junho de 2020. A análise da qualidade dos artigos foi baseada nos critérios do Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Síntese dos dados: Dez artigos foram selecionados nas bases de dados e dois incluídos por meio da busca manual, totalizando 12 estudos elencados. As amostras resultaram em 2.362 pacientes incluídos. Com base na iniciativa STROBE, sete estudos atenderam total e/ou parcialmente mais de 70% dos itens essenciais e dois atingiram menos que 60% deles, com variação geral de 86,4-54,5%. Os resultados mostram que os polimorfismos nos genes da proteína morfogenética óssea 6 (BMP6), da Klotho (KL) e da Anexina A2 (ANXA2) podem ter associação com osteonecrose no contexto da doença falciforme. Seis artigos estudaram o polimorfismo no gene da enzima MTHFR, mas apenas um obteve associação positiva. Os polimorfismos associados ao receptor DARC, ao gene ITGA4, ao CD36 e aos genes de proteínas trombofílicas não demonstraram associação em nenhum dos estudos. Conclusões: Os polimorfismos nos genes BMP6, KL e ANXA2 estão possivelmente associados com a necrose avascular em indivíduos com doença falciforme. Entretanto, para a confirmação dessas alterações genéticas como fatores de risco, é necessário que mais estudos com maior poder estatístico e com maior rigor metodológico sejam realizados.

Effect of Jianpi Huogu Formula on function damage of vascular endothelial cells induced by glucocorticoid / 中国中药杂志

This study aimed to observe the intervention effect of Jianpi Huogu Formula(JPHGF) on the functional damage of vascular endothelial cells caused by glucocorticoid, and explore its action mechanism from the PI3 K/Akt and mitogen activated protein kinase(MAPK) signaling pathways. The extracted thoracic aorta ring of normal SD rats were intervened first with vascularendothelial growth factor(VEGF, 20 μg·L-1) and/or sodium succinate(MPS, 0. 04 g·L-1) in vitro and then with JPHGF(8, 16, and 32 μg·L-1) for five mcontinuous ethylpdays, rednisolofollowed nebythe statistics of the number, length, and area of microvessels budding fromvascular rings. In addition, the human umbilical vein endothelial cells(HUVECs) induced by VEGF(20 μg·L-1) were added with MPS(0. 04 g·L-1) and then with JPHGF(8, 16, and 32 μg·L-1) for observing the migration, invasion, and luminal formation abilities of HUVECs in the migration, invasion and luminal formation experiments. The protein expression levels of PI3 K, p-Akt, p-JN K, and p-ERK in HUVECs were assayed by Western blot. The results showed that JPHGF dose-dependently improved the num-ber,length, and area of microvessels in MPS-induced rat thoracic aortic ring, reversed the migration, invasion and lumen formation abiliti es of HUVECs reduced by MPS, and up-regulated the protein expression levels of PI3 K, p-Akt, and p-JNK in HUVECs. All thesehave suggested that JPHGF exerts the protective effect against hormone-induced damage to the angiogenesis of vascular endothelial cells by activating the PI3 K/Akt and MAPK signaling pathways, which has provided reference for exploring the mechanism of JPHGF in treating s teroid-induced avascular necrosis of femoral head(SANFH) and also the experimental evidence for enriching the scientific connotationof spleen-invigorating and blood-activating therapy.

Osteoporosis and osteonecrosis in systemic lupus erythematosus / Osteoporosis y osteonecrosis en el lupus eritematoso sistémico

ABSTRACT Half of the patients with systemic lupus erythematosus (SLE) will have a reduced bone density and more than one in ten will develop osteoporosis (OP) prematurely. Multiple risk factors have been related to loss of bone mass, but just a few are modifiable, such as adequate vitamin D and calcium intakes, weight bearing exercise, controlling SLE activity and limiting the use of glucocorticoids (GC). GC have also been strongly associated to osteonecrosis or avascular necrosis (AVN). The main consequences of OP and AVN are fractures, which lead to significant functional limitation, loss of quality of life and increased morbidity. OP-related fractures can be reduced by performing appropriate screening with bone densitometries and providing prophylactic treatment when long-term or high dose GC are needed. No formal screening is available for AVN; but diagnosis is made by imaging (X-ray, bone scan or advanced imaging where appropriate). Aiming for the lowest dose possible of GC in combination with immunosuppression as well as an early recognition of the symptoms will prevent further complications. This manuscript is a practical review of the epidemiology, pathophysiology, and management of OP and AVN in patients with SLE, based on the available evidence and guidelines.

RESUMEN La mitad de los pacientes con lupus eritematoso sistémico (LES) tendrá una densidad ósea disminuida, y más de uno de cada 10 desarrollará osteoporosis (OP) prematuramente. Son múltiples los factores de riesgo que se han relacionado con la pérdida de la masa ósea, pero solo unos pocos son modificables, tales como la ingesta de niveles adecuados de vitamina D y de calcio, ejercicio con pesas, controlar la actividad del LES, y limitar el uso de glucocorticoides (GC). También se ha encontrado una estrecha relación entre el uso de GC y osteonecrosis o a necrosis avascular (NAV). Las principales consecuencias de la OP y de la NAV son fracturas, que generan una limitación funcional importante, pérdida de la calidad de vida y aumento de la morbilidad. Las fracturas por osteoporosis se pueden reducir mediante un tamizaje adecuado con densitometría ósea y administrando tratamiento profiláctico cuando se requieren GC de largo plazo o a altas dosis. No existe un tamizaje formal para la NAV, pero su diagnóstico se realiza con imágenes (radiografía, gammagrafía ósea o imágenes avanzadas cuando corresponda). El apuntar a la menor dosis posible de GC, en combinación con inmunosupresión, además de la temprana identificación de los síntomas, ayudará a prevenir otras complicaciones. El presente artículo es una revisión práctica de la epidemiología, la fisiopatología y el manejo de la OP y la NAV en pacientes con LES, en función de la evidencia y de las guías disponibles.

Enfermedad de Dieterich: reporte de un caso de una enfermedad muy poco frecuente / Dieterich's disease: a case report of a very rare disease

RESUMEN La enfermedad de Dieterich o necrosis avascular de la cabeza de los metacarpianos es una enfermedad muy poco frecuente, con poco más de 50 casos reportados en la literatura. De etiología desconocida, clínicamente se puede manifestar de forma variable, desde asintomática hasta con evidente inflamación y limitación funcional dolorosa de la articulación metacarpofalángica afectada. Presentamos el caso de un paciente de 82 anos que presentaba dolor a nivel de la articulación metacarpofalángica del tercer dedo de la mano derecha, de un año de evolución, sin causa aparente. La exploración física no evidenciaba limitación funcional, ni dolor; tampoco se objetivó eritema, tumefacción o efecto masa. Se realizó un estudio radiológico con diagnóstico de enfermedad de Dieterich avanzada, estableciendo tratamiento conservador con antiinflamatorios no esteroideos con mejoría clínica significativa.

ABSTRACT Dieterich's disease, or avascular necrosis of the metacarpal head, is a very rare disease, with just over 50 cases reported in the literature. Of unknown aetiology, it can manifest clinically in a variable way, from asymptomatic to obvious inflammation and painful functional limitation of the affected metacarpophalangeal joint. The case is presented of an 82-yearold patient who presented with pain at the level of the metacarpophalangeal joint of the third finger of the right hand of 1 year of duration without apparent cause. The physical examination showed no functional limitation or pain. Furthermore, no erythema, swelling, or mass effect was observed. A radiological study was carried out, leading to a diagnosis of advanced Dieterich's disease. Conservative treatment was started with nonsteroidal anti-inflammatory drugs, with a significant clinical improvement.

Contralateral Humerus Avascular Necrosis Diagnosed Immediately after Radiotherapy in a Patient with Breast Cancer

ABSTRACT Radiotherapy (RT) is an important component of treatment for malignant tumours, and avascular necrosis (AVN), which is often associated with high morbidity and disability, frequently accompanies this type of therapy. It generally develops in the same extremity with the treated region and may continue long after the treatment is completed. Early identification of AVN has the potential to reduce morbidity and improve the patient's quality of life. Herein, we present a case of contralateral humerus avascular necrosis diagnosed immediately after the first round of RT in a patient with breast cancer.

Characteristics and treatment of femoral neck fracture in children / 中华创伤骨科杂志

Femoral neck fracture in children is usually caused by high-energy trauma. This relatively rare injury characterized by skeletal immaturity is different from that in adult patients in proximal femoral anatomy and blood supply. Currently, a variety of fixation methods have been used for paediatric femoral neck fractures but their overall goal is anatomical reduction and stable fixation. Femoral neck fractures in children are usually associated with a high incidence of complications (e.g. femoral head necrosis, premature epiphyseal closure, coxa vara and nonunion) even after appropriate treatment. This review addresses the anatomic characteristics, treatment strategies and complications in the treatment of paediatric femoral neck fractures.

Necrosis avascular: complicación en un paciente joven / Avascular Necrosis: Complication in a Young Patient

Resumen: La presentación de una fractura de fémur proximal es totalmente diferente en pacientes jóvenes que en pacientes adultos. A diferencia de la fractura cerrada de fémur proximal, la incidencia de fracturas expuestas se encuentra en la población joven de entre 15 y 30 años de edad. Dentro de las complicaciones que podemos observar en estas fracturas se encuentra la osteonecrosis avascular (NAV) de la cabeza femoral, la cual se define como la interrupción del aporte sanguíneo a la cabeza femoral, ya sea por trauma, infección, alcoholismo o uso de esteroides, ocasionando necrosis ósea, colapso articular y osteoartrosis. El tratamiento dependerá de la presentación del caso, la edad del paciente y el tiempo en hacer el diagnostico. Se presenta el caso clínico de un paciente de 16 años de edad el cual ingresa al servicio de urgencias con diagnóstico de herida por arma de fuego a nivel de cadera izquierda. Se realiza lavado quirúrgico y reducción cerrada más fijación interna con clavo centro medular. Se da un seguimiento clínico y radiográfico por 3 años observando la evolución de la fractura y la subsecuente necrosis avascular que presenta el paciente.

Abstract: The clinical presentation of a proximal femoral fracture is completely different between young and adult patients. Unlike closed proximal femoral fractures, the incidence of exposed fractures is found in the young population between 15 and 30 years of age. Osteonecrosis of the femoral head is one the complications we can find in this type of fractures. Avascular necrosis (AVN or osteonecrosis) is defined as the interruption of blood supply to the femoral head due to trauma, infection, alcohol or steroid use, resulting in bone necrosis, joint collapse and osteoarthrosis. The treatment will depend on the clinical presentation, age of the patient and when the diagnosis is made. This is a case report of a 16-year-old patient with a gunshot wound on the hip. Surgical cleansing and closed reduction plus internal fixation with a nail in the center of the spine were performed. A 3-year clinical and radiographic follow up was made, observing the evolution of the fracture and the subsequent avascular necrosis that the patient presented.

Hip preservation experience of avascular necrosis of femoral head according to China-Japan Friendship Hospital classification / 中国修复重建外科杂志

Objective: To sum up staging treatment experiences of hip preservation for avascular necrosis of the femoral head (ANFH) according to China-Japan Friendship Hospital Classification (CJFH Classification). Methods: The literature about hip preservation of ANFH was extensively reviewed, and a staging treatment method for ANFH was set up base on CJFH Classification and the 28 years of clinical experience in this research group. Results: According to CJFH Classification, the ANFH can be rated as types M, C, and L. And the type L is rated as L1, L2, and L3 subtypes. The staging treatment method for ANFH based on CJFH Classification is set up. Conservative treatment was selected for CJFH-M patients because the necrotic area is small and in the medial non-weight-bearing area. Minimally invasive sequestrum clearance, impacting bone graft, and supporting allogenic fibular graft is selected for CJFH-C patients because the necrotic area is also small and in the lateral non-weight-bearing area. If patients are in CJFH-L1, normal bone area is less than 1/3 on hip abduction radiograph, the sequestrum clearance and impacting bone graft via surgical hip dislocation approach can be selected. If patients are in CJFH-L1, normal bone area is more than 1/3 on hip abduction radiograph, the transtrochanteric curved varus osteotomy can be selected. The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is for CJFH-L2 patients. Total hip arthroplasty via direct anterior approach is for CJFH-L3 patients. Conclusion: The staging treatment method for ANFH according to CJFH Classification has good short-term effectiveness. But the long-term effectiveness needs further follow-up.

Anatomy of pisiform blood supply and feasibility of vascularized pisiform transfer for avascular necrosis of lunate based on digital technique / 中国修复重建外科杂志

Objective: To provide anatomical basis for vascularized pisiform transfer in the treatment of advanced avascular necrosis of the lunate (Kienböck's disease) by studying its morphology and blood supply pattern based on digital technique. Methods: Twelve adult fresh wrist joint specimens were selected and treated with gelatin-lead oxide solution from ulnar or radial artery. Then the three-dimensional (3D) images of the pisiform and lunate were reconstructed by micro-CT scanning and Mimics software. The morphologies of pisiform and lunate were observed and the longitudinal diameter, transverse diameter, and thickness of pisiform and lunate were measured. The main blood supply sources of pisiform were observed. The number, diameter, and distribution of nutrient foramina at proximal, distal, radial, and ulnar sides of pisiform were recorded. The anatomic parameters of the pedicles (branch of trunk of ulnar artery, carpal epithelial branch, descending branch of carpal epithelial branch, recurrent branch of deep palmar branch) were measured, including the outer diameter of pedicle initiation, distance of pedicle from pisiform, and distance of pedicle from lunate. Results: There were significant differences in the longitudinal and transverse diameters between pisiform and lunate ( t=6.653, P=0.000; t=6.265, P=0.000), but there was no significant difference in thickness ( t= 1.269, P=0.109). The distal, proximal, radial, and ulnar sides of pisiform had nutrient vessels. The nutrient foramina at proximal side were significantly more than that at distal side ( P0.05). The outer diameter of pedicle initiation of the recurrent branch of deep palmar branch was significantly smaller than the carpal epithelial branch and descending branch of carpal epithelial branch ( P0.05), and between carpal epithelial branch and descending branch of carpal epithelial branch ( P>0.05). But the differences between the other vascular pedicles were significant ( P<0.05). Conclusion: There are abundant nutrient vessels at the proximal and ulnar sides of pisiform, so excessive stripping of the proximal and ulnar soft tissues should be avoided during the vascularized pisiform transfer. It is feasible to treat advanced Kienböck's disease by pisiform transfer with the carpal epithelial branch of ulnar artery and the descending branch.

Evaluation of multimodal analgesia in treatment of avascular necrosis of femoral head with free vascularized fibular grafting / 中国修复重建外科杂志

Objective: To prospective study the effectiveness and safety of multimodal analgesia (MA) in treatment of avascular necrosis of the femoral head with free vascularized fibular grafting (FVFG). Methods: Sixty patients with avascular necrosis of the femoral head, who were scheduled to unilateral primary FVFG between February 2016 and December 2016 and met the selection criteria, were included in the study. All patients were allocated to two groups according to the method of random number table: MA group ( n=30) and control group ( n=30). There was no significant difference in gender, age, body mass index, side, duration and stage of avascular necrosis of the femoral head, preoperative visual analogue scale (VAS) scores under quiescent and active states, and range of motion (ROM) of hip flexion and abduction before operation ( P>0.05). The patients in the MA group were treated with MA therapy, including oral administration of celecoxib before operation, local anesthetic wound infiltration during operation, and ice compression and oral administration of celecoxib after operation. The patients in control group were only treated with patient-controlled intravenous analgesia pump. The postoperative VAS scores under quiescent and active states, ROM of hip flexion and abduction, prescription of Tramadol and adverse reaction were recorded and compared. Results: The operations were completed successfully in both groups without obvious complications and adverse reaction. The Tramadol was used in 4 cases (13.3%) of MA group and in 11 cases (36.7%) of control group, but no significant difference was found between the two groups ( χ2=4.356, P=0.072). The VAS scores under quiescent state at 6 and 24 hours postoperatively were significantly lower in MA group than in control group ( P0.05). The ROM of hip flexion in MA group was better than that in control group at 1 day postoperatively and the day of discharge ( P0.05). The ROM of hip abduction in MA group was superior to the control group at 1, 2, and 3 days postoperatively and the day of discharge ( P<0.05). Conclusion: The MA can effectively relieve the pain following FVFG and facilitate early functional exercises of the hip. The usage of opioids was also relatively fewer for MA protocol.

Changes in serum levels of fibroblast growth factor-2, hypoxia-inducible factor-1alpha and vascular endothelial growth factor in patients with avascular necrosis of femoral head treated by enriched autologous bone marrow stem cell transplantation combined with core decompression / 中国组织工程研究

BACKGROUND: Avascular necrosis of the femoral head is mainly caused by insufficient blood supply of the femoral head. Core decompression is a common clinical treatment, enriched autologous bone marrow stem cell transplantation can improve hip function, and combined application can promote early recovery of patients. OBJECTIVE: To investigate the therapeutic effects of enriched autologous bone marrow stem cell transplantation combined with core decompression on serum levels of fibroblast growth factor-2, hypoxia-inducible factor-1α and vascular endothelial growth factor in patients with early avascular necrosis of femoral head. METHODS: Sixty-two cases of early avascular necrosis of femoral head treated from January 2016 to January 2018 were selected, and were divided into study group (n=31) and control group (n=31) according to the random number table method. The control group was treated with fine-needle porous-channel core pulp decompression, while the study group was treated with enriched autologous bone marrow stem cell transplantation on the basis of the control group. Harris score, Visual Analogue Scale score, serum fibroblast growth factor-2, hypoxia-inducible factor-1α and vascular endothelial growth factor levels and adverse reactions were observed before and after treatment. RESULTS AND CONCLUSION: (1) The Harris scores at 3, 6 and 12 months after treatment in the two groups were higher than those before treatment (P 0.05). (5) These results suggest that enriched autologous bone marrow stem cell transplantation combined with core decompression in the treatment of early avascular necrosis of femoral head can effectively improve hip joint function, promote the repair of femoral head necrosis area, alleviate pain, increase the level of fibroblast growth factor-2, and reduce the levels of hypoxia-inducible factor-1α and vascular endothelial growth factor.

Application of bisphosphonates in avascular necrosis of the femoral head / 中国组织工程研究

BACKGROUND: Animal experiments have shown that bisphosphonates exhibit a preventive effect on femoral head collapse. However, clinical application of bisphosphonates remains disputed. Systematic administration of bisphosphonates has many adverse reactions. There is an increasing number of studies on local application of bisphosphonates. OBJECTIVE: To review the research progress of bisphosphonates in the treatment of avascular necrosis of the femoral head. METHODS: The first authors (GJC and MJH) searched PubMed and CNKI databases to retrieve papers regarding bisphosphonate treatment of osteonecrosis of the femoral head using the search terms “osteonecrosis of the femoral head, bisphosphonates, systemic therapy, topical therapy, osteogenesis, bone destruction, bone remodeling” in English and Chinese. Sixty-two eligible papers were included in the final analysis. RESULTS AND CONCLUSION: It remains disputed whether bisphosphonates inhibit or activate osteoblasts. Current studies have shown that low concentration of bisphosphonates can promote the proliferation of osteoblasts, while high concentration of bisphosphonates can inhibit the proliferation of osteoblasts. Long term systematic application of bisphosphonates can induce mandibular osteonecrosis and other side effects. Topical application of bisphosphonates for treatment of avascular necrosis of the femoral head is still in the experimental stage. The optimal bisphosphonate concentration and the duration of efficacy in the treatment of avascular necrosis of the femoral head have not been determined. These should be clarified by in-depth high-quality experiments prior to clinical application.

Magnetic Resonance Imaging in Evaluation of Avascular Necrosis of Femoral Head

Introduction: Avascular necrosis (AVN) of the femoral head is one of the common causes of pain and disability of hip. Impairedblood supply and increased intraosseous pressure are predominantly responsible for the necrotic process, which eventuallyresults in collapse of the femoral head. Magnetic resonance imaging (MRI) is the preferred investigation for the evaluation of AVN.Aims and Objectives: This study aims to assess the role of MRI in the evaluation of clinically suspected cases of AVN of hipand to describe the imaging features along with proper staging.Materials and Methods: In this prospective study, 100 patients of all age groups with clinically suspected cases of AVN offemoral head were evaluated by MRI hip in the Department of Radiodiagnosis, Gandhi Medical College and Hamidia Hospitalover a period of 1 year. Detailed history and associated risk factors were asked from all patients. MRI hip was then performedon 1.5 Tesla Hitachi ECHELON SMART - 523 MRI machine using the required protocol and sequences. The imaging findingswere studied and proper staging was given.Results: In our study of 100 cases of AVN, 132 femoral heads were involved (unilateral 68 and bilateral 32 cases). The most commonrisk factor associated was alcohol consumption. The most common quadrant of femoral head affected was anterosuperior (49.3%). Themost common stage of AVN was found to be Grade III – 39.4% (Ficat and Arlet classification), Type C – 47% (Mitchell’s classification),and Stage IIIC – 37.8% (Steinberg classification). MRI could detect early AVN in 50 femoral heads, in which radiographs were normal.Conclusion: This study concludes that MRI is the modality of choice for diagnosing and staging AVN. Early diagnosis andappropriate treatment is associated with better outcome.