What is the role of core decompression in the early stages of osteonecrosis of the femoral head? Evaluation of the surgical result by functional score and radiological follow-up / Qual o papel da descompressão simples em estágios precoces na osteonecrose da cabeça femoral? Avaliação do resultado cirúrgico por meio de escore funcional e acompanhamento radiológico

ABSTRACT Objectives: This study is aimed at evaluating whether core decompression of the femoral head in the early stages of femoral head osteonecrosis improves patients' subjective perception of pain and avoids the progression of the disease to a femoral head collapse and a final indication of total hip arthroplasty. Methods: Eighteen patients (30 hips) in the early stages of the disease (Ficat and Arlet 1 and 2A) were evaluated through clinical, radiological, risk factor maintenance, and by the functional Merle D'Aubigné, and Postel score before and after core decompression of the femoral head. Results: There was an improvement of symptoms up to the sixth month in 83.3% of the hips evaluated through the Merle D'Aubigné and Postel score. However, 73.3% of the cases evolved with femoral head collapse, and in 50%, total hip arthroplasty was indicated regardless of whether or not the risk factors were maintained. Conclusions: Core decompression of the femoral head improves patients' pain early in the initial stages of the pathology. However, it does not alter the prognosis and the ultimate indication of total hip arthroplasty in the final stages of the disease.

RESUMO Objetivos: O presente estudo tem como objetivo avaliar se a descompressão simples da cabeça femoral nos estágios iniciais da osteonecrose da cabeça femoral melhora a percepção subjetiva da dor dos pacientes e se evita a progressão da doença para o colapso da cabeça femoral e a indicação final de artroplastia total do quadril. Métodos: Foram avaliados 18 pacientes (30 quadris) em estágios iniciais da doença (Ficat e Arlet 1 e 2 A) por critérios clínicos, radiológicos, manutenção dos fatores de risco e pela escala funcional de Merle D'Aubigné e Postel antes e após a descompressão simples da cabeça femoral. Resultados: Houve melhoria dos sintomas precocemente (até o sexto mês) em 83,3% dos quadris avaliados pela escala de Merle D'Aubigné e Postel. No entanto, 73,3% dos casos evoluíram com colapso da cabeça femoral e em 50% deles foi indicada artroplastia total do quadril, independentemente da manutenção ou não dos fatores de risco. Conclusões: A descompressão simples da cabeça femoral melhora a dor dos pacientes precocemente nos estágios iniciais da patologia. Entretanto, não altera o prognóstico da doença e a indicação final de artroplastia total do quadril nos estágios finais da doença.

Causas no traumáticas de necrosis avascular bilateral de la cabeza femoral: relación hepatitis C-interferón pegilado / Nontraumatic causes of bilateral avascular necrosis of the femoral head: link between hepatitis C and pegylated interferon

Antecedentes: La necrosis avascular de la cabeza femoral es una patología frecuente en pacientes con antecedentes de trauma, encontrándose como causas patologías vasculares, oncológicas, estados hipercoagulantes, tratamientos esteroideos prolongados, asociándose en algunos casos en pacientes con antecedente de hepatitis C con manejo con interferón pegilado + ribavirin. Seef, Foster y Poynard encontraron al estudiar el comportamiento del virus de la hepatitis, un estado de hipercoagulabilidad, que crea interrupción del flujo vascular retinacular en la cabeza femoral, sin incrementar la incidencia de osteonecrosis en este grupo de pacientes. Lauer expone que dichas infecciones virales llevan un proceso autoinmune, las cuales podrían producir vasculitis transitorias. Giampaolo en 2005 reporta la relación entre el uso de interferón en mieloma múltiple y otros padecimientos oncológicos relacionándose con necrosis avascular femoral. Material y métodos: Se valoraron los casos de diagnóstico de osteonecrosis bilateral de la cabeza femoral bilateral. Resultados: Se revisaron 5 pacientes, 4 mujeres y 1 hombre, con el diagnóstico de osteonecrosis bilateral de la cabeza femoral bilateral. Todos con antecedentes de hepatitis C con manejo con interferón pegilado, corroborándose diagnóstico definitivo por patología posterior a artroplastías, realizándose revisión bibliográfica de la relación de esta patología con el uso de interferón en pacientes con hepatitis C. Conclusiones: Al conocer la relación que existe en enfermedades virales como la hepatitis B y C con la presencia de estados de hipercoagulabilidad, procesos autoinmunes que conllevan a vasculitis transitorias y el uso de interferón pegilado 2B, relacionándose a necrosis avascular de las cabezas femorales, conoceremos nuevas causas asociadas no traumáticas a este padecimiento.

Background: Avascular necrosis of the femoral head is a frequent condition in patients with a history of trauma. The major pathologic causes include vascular diseases, malignancies, hypercoagulability states, long-term steroid treatment, and some patients have a history of hepatitis C infection treated with pegylated interferon and ribavirin. Upon studying the behavior of the hepatitis C virus, Seef, Foster and Poynard found a hypercoagulability state that causes interruption of retinacular blood flow to the femoral head, without an increased incidence of osteonecrosis in this patient group. Lauer states that such viral infections involve an autoimmune process and may result in transient vasculitides. Giampaolo, in 2005, reported the relationship between interferon use for multiple myeloma and other cancers and femoral avascular necrosis. Material and methods: Cases with a diagnosis of bilateral osteonecrosis of the femoral head were assessed. Results: Five patients were included, 4 females and one male, with a diagnosis of bilateral osteonecrosis of the femoral head. All of them had history of hepatitis C infection treated with pegylated interferon. The final diagnosis was proven by pathology after arthroplasty. A literature review was made of articles on the relationship between this condition and interferon use in patients with hepatitis C infection. Conclusions: Finding out the relationship between viral diseases such as hepatitis B and C infection and hypercoagulability states, autoimmune processes leading to transient vasculitides and the use of pegylated interferon 2B, will help us discover new nontraumatic causes associated with this condition.

Histomorphometric assessment of bone necrosis produced by two cryosurgery protocols using liquid nitrogen: an experimental study on rat femurs

OBJECTIVE: The aim of this study was to evaluate the effects of liquid nitrogen cryosurgery on the femoral diaphysis of rats. MATERIAL AND METHODS: The femoral diaphyses of 42 Wistar rats were exposed to three local and sequential applications of liquid nitrogen for 1 or 2 min, intercalated with periods of 5 min of passive thawing. The animals were sacrificed after 1, 2, 4 and 12 weeks and the specimens obtained were processed and analyzed histomorphometrically. RESULTS: The depth and extent of peak bone necrosis were 124.509 µm and 2087.094 µm for the 1-min protocol, respectively, and 436.424 µm and 12046.426 µm for the 2-min protocol. Peak necrosis was observed in the second experimental week with both cryotherapy protocols. CONCLUSIONS: The present results indicate that the 2-min protocol produced more marked bone necrosis than the 1-min protocol. Although our results cannot be entirely extrapolated to clinical practice, they contribute to the understanding of the behavior of bone tissue submitted to different cycles of liquid nitrogen freezing and may serve as a basis for new studies.

Free vascularized fibula graft for a cystic femoral head and neck lesion in the West Indies

A case is presented of an 18-year-old athlete with fibrous dysplasia of the femoral neck and head. The approach was by joint plastic and orthopaedic teams, which minimized operating time and allowed the option of vascular bone grafting. The lesion was curetted through a greater trochanteric window and the defect reconstructed with a free vascularized fibula graft with excellent result. Weight bearing was achieved in six months and there was minimal donor site morbidity. We believe the free vascularized fibula graft to be a reconstructive option, in difficult orthopaedic problems, facilitated by microsurgery and there is immense benefit of a joint effort between the orthopaedic and plastic surgical teams

Osteonecrosis aséptica de la cabeza del fémur: desde la clínica / Femur head aseptic osteonecrosis: clinical view

La osteonecrosis aséptica de cabeza de fémur es una enfermedad de etiología multifactorial y tratamiento multidisciplinario. Presentamos nuestra casuística, enfatizando en los aspectos clínicos y etiopatogénicos. Consideramos que el médico generalista desempeña un rol trascendente en el diagnóstico precoz de esta enfermedad.

Comparaçäo entre radiografia, cintilografia, tomografia computadorizada e anatomopatológico na avaliaçäo da necrose asséptica da cabeça femoral / Comparison among radiography, scintigraphy, computerized tomography and anatomo-pathological in the evaluation of aseptic necrosis of the femoral head

Os autores estudaram sete quadris de cinco pacientes portadores de necrose asséptica da cabeça do fêmur quanto aos aspectos clínico, radiológico, cintilográfico, de tomografia computadorizada e histológico. A tomografia computadorizada mostrou-se como método principal no diagnóstico precoce, no estadiamento, na análise quantitativa e na localizaçäo da área de necrose. O exame histológico confirmou a patologia em todos os casos. Os poucos dados fornecidos pelo exame radiográfico nos estágios iniciais, a importância do tratamento precoce e a progressäo para a osteoartrose como curso natural da doença fazem com que outros métodos sejam imperativos para melhor avaliaçäo desta patologia nessas fases

La Necrosis Avascular de la Epífisis Femoral en el Tratamiento Quirúrgico de la Luxación Congénita de la Cadera

Se estudia retrospectivamente la evolución clínica y radiológica de 220 caderas en 170 pacientes, con luxación Congénita de Cadera (LCC), durante los años de 1978 a 1982, tratados mediante reducción abierta, por vía anterior o por vía interna, completamentada o no con acetabuloplastia, osteotomía femoral o ambas. Se utilizaron los criterios de Salter y Kostuik para el diagnóstico de la Necrosis Avascular (N.A.) y las valorizaciones funcionales de McKay y radiológicas de Severin para los resultados finales. Se relacionó el estado previo del núcleo cefálico con la altura de la luxación, el tipo de necrosis desarrollado y el procedimiento quirúrgico empleado. Encontramos una incidencia global de 17.7 por ciento de necrosis avasculares, siendo el 78.1 por ciento de éstas, necrosis isquémicas mediales transitorias o necrosis avasculares del tipo I de Kalamchi cuyos resultados finales tanto clínicos como radiológicos fueron satisfactorios