Serological index PAI-1 as risk factor of complications of femoral head necrosis after internal fixation of femoral neck fracture / 国际检验医学杂志

Objective To investigate the risk factors of femoral head necrosis after internal fixation of fem-oral neck fracture,and to clarify the predictive role of serological index plasminogen activator inhibitors-1(PAI-1)on femoral head necrosis.Methods A total of 95 patients undergoing internal fixation for femoral neck fracture were included in the study.Relevant clinical information of patients was obtained and the serum PAI-1 levels of the patients before surgery,1,2,and 3 days after surgery were detected.After 1-year follow-up,patients were divided into necrosis group and non-necrosis group according to the occurrence of femoral head necrosis.Visual Analog Scale(VAS),Western Ontario McMaster University Osteoarthritis Index(WOMAC),and Harris Hip Score(HHS)were conducted in all patients one year after the surgery.The differences of basic clinical information and serum PAI-1 levels before and after the surgery between necrosis group and non-necrosis group were compared,and Logistic regression analysis was performed to identify the relevant risk factors for femoral head necrosis.The relationships between the PAI-1 level after operation and the VAS,WOMAC,and HHS scores of patients were figured out.The receiver operating characteristic(ROC)curve of serum PAI-1 as a predictive indicator for femoral head necrosis was drawn to clarify its predictive val-ue.Results Garden classification and reduction quality between the necrosis group and the non-necrosis group were risk factors for femoral head necrosis(P＜0.05).The serum PAI-1 at 1 day and 2 days after surgery in the necrosis group were significantly higher than that in the non-necrosis group(P＜0.05).The level of PAI-1 at 1 day and 2 days after surgery was positively correlated with VAS and WOMAC(P＜0.05),and negative-ly correlated with HHS(P＜0.05).Logistic regression analysis showed that the increase of serum PAI-1 level at 1 day and 2 days after surgery were risk factors for femoral head necrosis(P＜0.05).The ROC curve showed that serum PAI-1 level at 2 days after surgery had higher predictive value than that at 1 day after sur-gery,and the cut-off value was 44.8 ng/L,the sensitivity was 68.49％,the specificity was 86.36％,and the ar-ea under the curve(AUC)was 0.807.Conclusion The serum PAI-1 level at 1 day and 2 days after internal fixation of femoral neck fracture could be used to predict the occurrence of femoral head necrosis,especially the serum PAI-1 levels at 2 days after surgery.

Finite element analysis of osteoporosis in proximal femur after cannulated screw fixation for femoral neck fracture / 中国组织工程研究

BACKGROUND:After the internal fixation of cannulated screws in femoral neck fractures,because the affected limb is often unable to bear weight in the short term and the implants with high stiffness have a stress shielding effect on the fracture end,it is easy to cause osteoporosis of the affected limb and changes in the biomechanical distribution of the proximal femur,the incidence of osteonecrosis of the femoral head is high after surgery.At present,few studies have been conducted on the biomechanical effects of osteoporosis at the proximal end of the femur occurring after femoral neck fracture surgery on femoral neck fracture treated with cannulated screws. OBJECTIVE:Using finite element analysis,to investigate the biomechanical effects of osteoporosis occurring after femoral neck fracture surgery on femoral neck fracture treated with cannulated screws and explore the role of biomechanical factors in osteonecrosis of the femoral head. METHODS:Based on the obtained CT scan data of the femur in a patient with a femoral neck fracture,a proximal femoral model for internal fixation for femoral neck fracture was established by Mimics 19.0,3-Matic,UG 11.0,Hypermesh 14.0,and Abaqus software.One finite element model of the proximal femur without osteoporosis and three finite element models of the proximal femur with osteoporosis were analyzed using Abaqus software.The stress,contact pressure,displacement peak and cloud map under different components of the four models were measured and analyzed,and the internal stress changes and distribution of the femoral head were compared and analyzed. RESULTS AND CONCLUSION:The stresses and contact pressures of the femoral head and lower anterior cannulated screws varied more with the degree of osteoporosis.The peak displacement of the four models increased slowly with the degree of osteoporosis.By one-way analysis of variance,there was no significant effect of the degree of osteoporosis on the peak stress,contact pressure,and displacement of the different components.The internal stress distribution of the femoral head changed with the degree of osteoporosis.Changes in the biomechanical environment of the proximal femur have an important impact on osteonecrosis of the femoral head.

Identification of differences in N6-methyladenosine-related genes in steroid-induced femoral head necrosis / 中国组织工程研究

BACKGROUND:It is known that N6-methyladenosine(m6A)plays a role in the pathogenesis of various diseases and studies have suggested its involvement in the pathologic changes of steroid-induced femoral head necrosis(SNFH).However,research on m6A methylation modifications in steroid-induced femoral head necrosis is limited. OBJECTIVE:Using bioinformatics methods to identify the differential expression of m6A-related genes in steroid-induced femoral head necrosis and to predict miRNAs associated with these genes to further elucidate the role and mechanism of m6A methylation in steroid-induced femoral head necrosis. METHODS:Differential gene expression between steroid-induced femoral head necrosis and control groups was analyzed using GSE123568 gene expression data and identified using the"limma"package in R.Functional enrichment analysis was performed on the differentially expressed genes.Differential analysis of the related genes was carried out using the"ggstatsplot"package in R.The differential genes were cross-validated using the GSE74089 dataset.An mRNA-miRNA regulatory network was constructed,and co-expression analysis was performed on the module genes followed by enrichment analysis.Differences in immune cell infiltration between steroid-induced femoral head necrosis and control groups were quantified using the ssGSEA method. RESULTS AND CONCLUSION:Correlation analysis revealed 13 m6A-related genes,and further analysis through the protein-protein interaction network identification and receiver operating characteristic curve analysis showed that YTHDF2 was expected to be a core differential gene as a potential early biomarker.Enrichment analysis indicated that differentially expressed genes were mainly involved in inflammation and immune response and were closely related to osteoclasts.Cross-validation analysis showed that differential gene expression results between the two datasets were consistent.mRNA-miRNA regulatory network analysis revealed that YTHDF2 was negatively correlated with miRNA-27a.Immune infiltration analysis revealed an increase in immune cell infiltration in steroid-induced femoral head necrosis,and YTHDF2 was positively correlated with the infiltration of CD4+T cells.To conclude,m6A-related gene YTHDF2 can serve as a potential biomarker of steroid-induced femoral head necrosis and is valuable for the early clinical diagnosis and treatment of steroid-induced femoral head necrosis.The negative correlation between YTHDF2 and mir-27a and the positive correlation between YTHDF2 and CD4+T cell infiltration provide new insights into the early diagnosis and treatment of steroid-induced femoral head necrosis and shed light on the mechanism of m6A in steroid-induced femoral head necrosis.

Applicable techniques for subchondral separation of femoral head necrosis treated by tissue engineering / 中国组织工程研究

BACKGROUND:The appearance of the crescent sign in femoral head necrosis is a"turning point"in the progression of the disease,and repairing and stabilizing the bone-cartilage interface is particularly important in preventing further progression and collapse of the femoral head.Tissue engineering offers potential advantages in the simultaneous repair and integration of the bone-cartilage interface. OBJECTIVE:To review potentially suitable techniques addressing the subchondral separation in femoral head necrosis. METHODS:Relevant articles from January 1970 to April 2023 were searched in PubMed,Web of Science,and China National Knowledge Infrastructure(CNKI)using English search terms"femoral head necrosis,avascular necrosis of femoral head,osteonecrosis of femoral head"and Chinese search terms"femoral head necrosis,subchondral bone,cartilage,integration of cartilage and subchondral bone".A total of 114 articles were included for review and analysis. RESULTS AND CONCLUSION:(1)Structural defects,ischemic and hypoxic environment,inflammatory factors,and stress concentration may cause subchondral separation in osteonecrosis of the femoral head.Subchondral bone collapse and failure of hip-preserving surgery may be associated.Integration of tissue engineering scaffolds with the bone-cartilage interface is one potential approach for treating subchondral separation in osteonecrosis of the femoral head.(2)Current literature suggests that multiphase scaffolds,gradient scaffolds,and composite materials have shown improvements in promoting cell adhesion,proliferation,and deposition of bone and cartilage matrix.These advancements aid in the integration of scaffolds with the bone-cartilage interface and have implications for the treatment of subchondral separation in osteonecrosis of the femoral head.(3)Surface modifications of scaffolds can enhance interface integration efficiency,but they have their advantages and disadvantages.Scaffolds providing different environments can induce differentiation of mesenchymal stem cells and facilitate integration between different interfaces.(4)Future scaffolds for subchondral separation in osteonecrosis of the femoral head are expected to be composite materials with gradient and differentiated biomimetic structures.Surface modifications and stem cell loading can promote integration between the bone-cartilage interface and scaffolds for therapeutic purposes,but further experimental verification is still needed.Challenges include synchronizing scaffold degradation rate with repair progress and ensuring stability between different interfaces.

Exosome-derived microRNA with bone and joint diseases:role and mechanism / 中国组织工程研究

BACKGROUND:Exosomes are vesicle-like structures secreted by cells into extracellular compartments in the form of cytosol,which contain a large amount of microRNAs with important intercellular communication roles.MicroRNAs in exosomes rely on exosome transport and are able to enter target cells to exert important biological regulatory effects.In common bone and joint diseases,abnormal or damaged bone metabolism releases a large number of exosomes,while some exosome-derived microRNAs also promote the progression of osteoarthritis.Therefore,exosome-derived microRNAs are closely related to the skeletal system and are important for the development as well as diagnosis and treatment of many osteoarticular diseases. OBJECTIVE:To review the research progress of exosome-derived microRNAs in bone metabolism and bone and joint diseases. METHODS:Using"exosomes,extracellular vesicle,microRNA,miRNA,bone,bone diseases,bone formation,bone regeneration,bone resorption,bone destruction"as Chinese and English search terms,articles were searched on CNKI,Metasys,and PubMed databases.Finally,86 articles were included for summarization. RESULTS AND CONCLUSION:Exosome-derived microRNAs can regulate bone metabolism by affecting bone formation and bone resorption,and are closely related to the development of bone and joint diseases such as fracture healing,osteoporosis,osteoarthritis,rheumatoid arthritis,osteonecrosis of the femoral head,and osteosarcoma.Exosome-derived microRNAs will be an effective means of diagnosis and treatment of certain bone and joint diseases in the future.However,the current research on exosome-derived microRNAs in osteoarthritic diseases is limited,and more explorations and researches are still needed to diagnose and treat osteoarthritic diseases using exosome-derived microRNAs.

Action mechanism of gluteus medius width ratio in progression of non-traumatic femoral head necrosis by finite element analysis / 中国组织工程研究

BACKGROUND:The gluteus medius not only abducts the hip joint,but also plays an important role in limiting the external movement of the femoral head.At present,there is a lack of research on the correlation between gluteus medius status and non-traumatic femoral head necrosis. OBJECTIVE:To investigate the relationship between the gluteus medius width ratio and the medial space ratio of the hip joint and the progression of non-traumatic femoral head necrosis,and to explore the effect of gluteus medius atrophy on the surface and necrotic zone stress of the femoral head necrosis through finite element analysis. METHODS:Retrospective analysis of unilateral non-traumatic femoral head necrosis patients admitted to Third Affiliated Hospital of Guangzhou University of Chinese Medicine was performed.All patients were followed up for an average of more than 2 years.They were divided into a collapsed group and a non-collapsed group based on whether there was collapse of the femoral head during the follow-up.Medial space ratio,gluteus medius width ratio,Sharp angle,gluteus medius length ratio,and gluteus medius activation angle were measured and calculated.The differences in these indicators were compared between the two groups.At the first visit and follow-up at 3,6,12,and 24 months,the medial space ratio and gluteus medius width ratio were measured and calculated to explore the changes of these two indicators in the course of non-traumatic femoral head necrosis.In addition,using three-dimensional finite element analysis,a Japanese Investigation Committee classification C1 type femoral head necrosis model was constructed based on CT data.At the same time,based on MRI data,a model of the gluteus medius muscle was constructed and divided into a gluteus medius muscle atrophy group(gluteus medius width ratio:74%-76%)and a gluteus medius muscle normal group(gluteus medius width ratio:94%-96%).Each group constructed 10 models,with 6 degrees of freedom of the distal femur constrained to zero.600 N pressures were applied along the Z-axis to the upper surface of the sacrum.The stress distribution,maximum stress values on the surface and necrotic area of the femoral head,and the maximum displacement of the necrotic area were compared between two groups of models. RESULTS AND CONCLUSION:(1)A total of 153 patients(67 males and 86 females)with 153 hips were included in this study.(2)At the 24-hour follow-up,the medial space ratio of the collapsed group was significantly higher than that of the non-collapsed group(P<0.05).The gluteus medius width ratio of the collapsed group was significantly lower than that of the non-collapsed group(P<0.05).There was no statistically significant difference in Sharp angle,gluteus medius activation angle,and gluteus medius length ratio between the two groups(P>0.05).(3)Since the follow-up time exceeded 3 months,the gluteus medius width ratio of the collapsed group was lower than that of the non-collapsed group(P<0.05).Since the follow-up time exceeded 12 months,the medial space ratio of the collapsed group was higher than that of the non-collapsed group(P<0.05).(4)Pearson correlation analysis showed a significant positive correlation between follow-up time and medial space ratio in the collapsed group(P<0.05),and a significant negative correlation between follow-up time and gluteus medius width ratio(P<0.05).The regression coefficient of gluteus medius width ratio was larger than that of medial space ratio.(5)The group with middle gluteal muscle atrophy showed significant stress concentration on the surface of the femoral head,and the stress zone was significantly located on the outside.The maximum stress on the surface of the femoral head in the group with middle gluteal muscle atrophy was significantly greater than that in the group with normal middle gluteal muscle(P<0.05).There was significant stress concentration in the necrotic area of the middle gluteal muscle atrophy group,and the maximum stress was located at the edge of the necrotic area.The maximum stress and maximum displacement in the necrotic area of the middle gluteal muscle atrophy group were significantly greater than those of the normal group(P<0.05).(6)It is indicated that gluteus medius width ratio is an effective indicator for evaluating changes in gluteal muscle atrophy.In the progression of non-traumatic femoral head necrosis,atrophy of the gluteus medius muscle first occurs,followed by widening of the medial hip joint space.The mechanical mechanism may be that the atrophy of the gluteus medius muscle affects the stability of the hip joint,leading to external displacement of the femoral head,and increasing stress and displacement on the surface and necrotic area of the femoral head.

Modified Dunn Technique for Unstable Slipped Capital Femoral Epiphysis: A Midterm Single Center Experience / Técnica de Dunn modificada no escorregamento da epífise femoral proximal com instabilidade: Experiência unicêntrica de médio prazo

Abstract Objective To evaluate the safety and reproducibility of the surgery for unstable slipped capital femoral epiphysis (SCFE) through the modified Dunn technique in a single center cohort from Brazil. Methods We retrospectively analyzed a cohort of patients submitted to this procedure by a single surgeon who was a hip preservation specialist. Demographic data and radiographic angles were evaluated for the relative risk (RR) of avascular necrosis (AVN) using a log-binomial regression model with simple and random effects. Results Among the 30 patients (30 hips) with a mean age of 11.79 years at the time of the operation, there were 17 boys and 18 left hips, which were operated on in a mean of 11.5 days after the slip. The mean follow-up was of 38 months. The preoperative Southwick angle averaged 60.69° against 4.52° postoperatively (p< 0.001). A larger preoperative slip angle was associated with the development of AVN (RR: 1.05; 95% confidence interval [95%CI]: 1.02-1.07; p< 0.01). The overall AVN rate was of 26.7%. Function was good or excellent in 86% of uncomplicated hips, and poor in 87.5% of the partients who developed AVN, as graded by the Harris Hip Score. There was no statistical relationship between epiphyseal bleeding and AVN development (p= 0.82). Conclusion The modified Dunn technique is associated with restoration of the femoral alignment and function after unstable SCFE, when uncomplicated. Moreover, it was shown to be reproducible in our population, with a rate of 26% of femoral head necrosis.

Resumo Objetivo Avaliar a segurança e a reprodutibilidade da cirurgia para escorregamento da epífise femoral proximal (EEPF) com instabilidade por meio da técnica de Dunn modificada em uma coorte unicêntrica no Brasil. Métodos Analisamos de forma retrospectiva uma coorte de pacientes submetidos a esse procedimento por um único cirurgião especialista em preservação do quadril. Avaliamos os dados demográficos e os ângulos radiográficos quanto ao risco relativo (RR) de necrose avascular (NAV) por meio do modelo de regressão log-binomial com efeitos simples e aleatórios. Resultados Entre os 30 pacientes (30 quadris) com idade média de 11,79 anos no momento da cirurgia, havia 17 meninos e 18 quadris esquerdos. O procedimento ocorreu em média 11,5 dias após o escorregamento. O tempo médio de acompanhamento foi de 38 meses. O ângulo de Southwick pré-operatório foi, em média, de 60,69° contra 4,52° após o procedimento (p< 0,001). O maior ângulo de escorregamento pré-operatório foi associado ao desenvolvimento de NAV (RR: 1,05; intervalo de confiança de 95% [IC95%]: 1,02-1,07; p< 0,01). A frequência geral de NAV foi de 26,7%. De acordo com a Escala de Quadril de Harris (Harris Hip Score), a função foi boa ou excelente em 86% dos quadris sem complicações, e ruim em 87,5% dos casos com NAV. Não houve relação estatística entre sangramento epifisário e desenvolvimento de NAV (p= 0,82). Conclusão A técnica de Dunn modificada restaura o alinhamento femoral e a função articular após o EEPF com instabilidade na ausência de complicações. Além disso, mostrou-se passível de reprodução em nossa população, com frequência de necrose da cabeça femoral de 26%.

Active Components in Chinese Medicinal Herbs Regulate Osteogenic Signaling Pathway in Treatment of Steroid-induced Osteonecrosis of Femoral Head： A Review / 中国实验方剂学杂志

As a threat to human health， steroid-induced osteonecrosis of femur head is a common refractory orthopedic disease mainly caused by glucocorticoids， with poor prognosis and unclear pathogenesis. Osteogenesis-associated signaling pathways play an important role in bone formation. Glucocorticoid-induced abnormal activation and transport of these signaling pathways lead to abnormal differentiation of bone marrow mesenchymal stem cells， dysfunction of bone metabolism， and osteogenesis disorders， which may be the main reasons for the occurrence and development of steroid-induced osteonecrosis of femur head. Bone formation and remodeling need the participation of bone marrow mesenchymal stem cells， which are stem cells characterized by continuous self-renewal and differentiation. The key to strengthening bone remodeling is to improve the osteogenic differentiation capacity， which is the key point to inhibit bone resorption and prevent bone marrow mesenchymal stem cells from differentiating into osteoclasts. Traditional Chinese medicine （TCM） has been used in the treatment of osteonecrosis in ancient times. It is recorded in the Treasury of Words on Materia Medica （《本草汇编》） that "The deficiency in the lower energizer cannot be tonified without Eucommiae Cortexz.The soreness in lower legs cannot be alleviated without Eucommiae Cortex...The pain in the waist and knee cannot be relieved without Eucommiae Cortex...Tonifying liver and invigorating kidney， Eucommiae Cortex is an essential medicine." This indicates that ancient physicians have already begun to use the liver-tonifying， kidney-invigorating， and sinew-bone-strengthening effects of Eucommiae Cortex for the treatment of osteonecrosis. As the national support for the development of TCM strengthens， increasing studies have been conducted on the TCM prevention and treatment of steroid-induced osteonecrosis of femur head. Studies have suggested that Chinese medicinal herbs can exert a positive effect on the differentiation of bone marrow mesenchymal stem cells by affecting targeted signaling molecules， and promote osteogenesis and bone defect repair， thus combating the occurrence and development of steroid-induced osteonecrosis of femur head. The regulation of osteogenic signaling pathway by Chinese medicines to prevent steroid-induced osteonecrosis of femoral head has become a hot research topic. This article reviews the studies about the prevention and treatment of steroid-induced osteonecrosis of femur head with the active components in Chinese medicinal herbs by regulating osteogenic signaling pathways. We then explore the mechanism of the active components in promoting the differentiation of bone marrow mesenchymal stem cells into osteoblasts and inhibiting their differentiation into osteoclasts to facilitate bone formation， aiming to provide a reference for the further study of treating steroid-induced osteonecrosis of femoral head with Chinese medicinal herbs.

Imaging measurement and analysis of related indexes of variation of femoral head rotation center / 中国骨伤

OBJECTIVE@#To provide guidance for hip replacement by analyzing the variation of femoral head rotation center in different hip diseases.@*METHODS@#A total of 5 459 patients were collected from March 2016 to June 2021, who took positive and proportional plain films of both hips for various reasons. The relative position between the rotation center of the femoral head and the apex of the greater trochanter was measured. The positive variation is more than 2 mm above the top of the great trochanter, and the negative variation is more than 2 mm below the top of the great trochanter. A total of 831 patients with variation of femoral head rotation center were collected and were divided into 4 groups according to different diseases, and the variation was counted respectively. There were 15 cases in the normal group involving 10 cases of positive variation and 5 cases of negative variation. There were 145 cases of avascular necrosis of femoral head involving 25 cases of positive variation and 120 cases of negative variation. There were 346 cases of congenital hip dysplasia involving 225 cases of positive variation(including 25 cases of typeⅠ, 70 cases of type Ⅱ, 115 cases of type Ⅲ and 15 cases of type Ⅳ), and 121 cases of negative variation(including 50 cases of crowe typeⅠ, 60 cases of typeⅡ, 10 cases of type Ⅲ and 1 case of type Ⅳ). There were 325 cases of hip osteoarthritis group involving 45 cases of positive variation and 280 cases of negative variation.@*RESULTS@#There was significant difference in variation of femoral head rotation center among the four groups(P<0.05). There was significant difference in variation of femoral head rotation center among different types of congenital hip dysplasia(P<0.05). There were significant differences in cervical trunk angle and eccentricity among different variations of femoral head rotation center(P<0.05).@*CONCLUSION@#The variation of femoral head rotation center is related to cervical trunk angle and eccentricity. The variation of femoral head rotation center is an important factor in hip diseases. The variation of femoral head rotation center is different in different hip diseases. Avascular necrosis of the femoral head and osteoarthritis of the hip were mostly negative variations. With the aggravation of congenital hip dysplasia, the variation of femoral head rotation center gradually changed from negative variation to positive variation.The variation of femoral head rotation center should be paid attention to in the preoperative planning of hip arthroplasty. It is of great significance to select the appropriate prosthesis and place the prosthesis accurately.

Clinical study on core decompression in treating osteonecrosis of the femoral head of the necrotic bone-in different site / 中国骨伤

OBJECTIVE@#To analyze the clinical effect of decompression and bone grafting on osteonecrosis of the femoral head(ONFH) at different sites of necrotic lesions.@*METHODS@#A total of 105 patients with ARCOⅡstage ONFH admitted from January 2017 to December 2018 were retrospectively analyzed. There were 71 males and 34 females, with an average age of (55.20±10.98) years old. The mean course of all patients was(15.91±9.85) months. According to Japanese Inveatigation Committee (JIC) classification, all patients were divided into 4 types:17 cases of type A, 26 cases of type B, 33 cases of type C1 and 29 cases of type C2. All four groups were treated with decompression of the pulp core and bone grafting. Visual analogue scale(VAS) and Harris hip joint score were used before and at 3, 6, 12, and 24 months after the operation, and the collapse of the femoral head was observed by X-ray examination within 2 years.@*RESULTS@#All 105 patients were successful on operation without complications, and the mean follow-up duration was (24.45±2.75) months. Harris score showed that there was no statistical difference among four groups before surgery and 3, 6 months after surgery (P>0.05);at 12 and 24 months after surgery, there were significant differences among all groups (P<0.01). There were significant differences in intragroup Harris scores at preoperative and postoperative time points among four groups (P<0.01). VAS showed that there was no statistical difference among four groups before and 3, 6 months after surgery (P>0.05);at 12 and 24 months after surgery, there were significant differences among all groups (P<0.01). There were significant differences in VAS at preoperative and postoperative time points among four groups (P<0.01). None of the patients in four groups had femoral head collapse before and 3, 6 months after surgery. At 12 months after operation, there were 3 cases of femoral head collapse in group C and 4 cases in group C2(P>0.05);At 24 months after operation, 1 case of femoral head collapse occurred in group B, 6 cases in group C1 and 8 cases in group C2(P<0.05).@*CONCLUSION@#Core decompression and bone grafting can improve the effect of ONFH and hip preservation. The effect of hip preservation for ONFH is closely related to the location of the osteonecrosis lesion, so the influence of the location of lesion on the effect of hip preservation should be considered in clinical treatment, so as to make better preoperative hip preservation plan.

Primary repair for concurrent bilateral intertrochanteric fracture and femoral head necrosis with prolonged shank biologic total hip replacement: A case report and surgical techniques / 中华创伤杂志(英文版)

For the treatment of an intertrochanteric fracture combined with femoral head necrosis in middle-age patients, it has been controversial whether to perform fracture reduction and fixation first then total hip replacement, or direct total hip replacement. We present a rare case of 53-year-old male patient suffered from bilateral intertrochanteric fracture caused by a road traffic injury. The patient had a history of femoral head necrosis for eight years, and the Harris score was 30. We performed total hip replacement with prolonged biologic shank prostheses for primary repair. One year after the surgery, nearly full range of motion was achieved without instability (active flexion angle of 110°, extension angle of 20°, adduction angle of 40°, abduction angle of 40°, internal rotation angle of 25°, and external rotation angle of 40°). The Harris score was 85. For the middle-aged patient with unstable intertrochanteric fractures and osteonecrosis of the femoral head, we can choose primary repair for concurrent bilateral intertrochanteric fracture and femoral head necrosis with prolonged shank biologic total hip replacement.

Investigation on Mechanisms of Osteoking Against Four Types of Bone Injury Diseases Based on Heterogeneous Information Network with Concept of "Treating Different Diseases with an Identical Treatment" / 中国实验方剂学杂志

ObjectiveTo elucidate the mechanism of Osteoking against fracture， femoral head necrosis， osteoarthritis， and lumbar disc herniation by integrating heterogeneous information network mining and experimental validation. MethodOn the basis of the disease-related database and transcriptome expression profiling dataset， as well as the ETCM database， the gene sets related to four target diseases and the candidate target spectrum of Osteoking were obtained through the integration and analysis of bioinformatics data， and a "disease-syndrome-formula-target-pathway-effect" heterogeneous information network was constructed. In addition， by functional enrichment analysis， the core targets of Osteoking in interfering with the imbalance network of four kinds of bone injury diseases， the biological pathways involved， and the corresponding clinical symptoms were screened， and they were verified in animal experiments. ResultHeterogeneous information network mining indicates that Osteoking may commonly reverse the imbalance networks of fracture， femoral head necrosis， osteoarthritis， and lumbar disc herniation via regulating cell function and activity， inhibiting inflammatory response， reducing bone destruction， and improving the immune function of the body by modulating relevant core candidate targets such as RAC-alpha serine/threonine-protein kinase （Akt1）， catenin beta-1 （CTNNB1）， epidermal growth factor receptor （EGFR）， heat shock protein 90-alpha （HSP90AA1）， and phosphatidylinositol 3-kinase catalytic subunit alpha isoform （PI3KCA）， as well as related biological pathways such as phosphatidylinositide 3-kinases/protein kinase B （PI3K/Akt）， janus kinase/signal transducer and activator of transcription （JAK/STAT）， tumor necrosis factor （TNF）， nuclear factor kappa-B （NF-κB）， and Toll-like receptors. In particular， Osteoking may improve the blood supply of the fracture end by regulating blood circulation at the target site of the disease， and it may maintain the balance of bone metabolism by regulating hormone-related pathways to promote fracture healing. In addition， Osteoking may relieve lipid metabolism disorders by targeting and regulating lipid-related pathways， accelerate bone formation and bone repair， and delay the progression of femoral head necrosis. Osteoking may relieve the symptoms of pain by acting on neurological pathways to reduce local nociceptive stimulation in patients with osteoarthritis and lumbar disc herniation. Further experimental validation demonstrates that the PI3K/Akt signaling pathway is the most significantly enriched pathway for the key network targets of Osteoking for the four diseases. The candidate target of Osteoking may have the strongest association with the network of fracture-related genes. Therefore， this study chooses fracture as the target disease to verify the efficacy of Osteoking. The results show that Osteoking can accelerate bone formation and promote fracture healing by inhibiting the activation of the PI3K/Akt signaling axis. ConclusionThe study shows that the main mechanism of "treating different diseases with an identical treatment" of four bone injury diseases with Osteoking involves cell function regulation and immune inflammation-related signaling pathways. Further experimental validation identifies that the PI3K/Akt signaling axis may be one of the key pathways of Osteoking to promote bone regeneration， bone reconstruction， and bone metabolism homeostasis.

Robot-assisted core decompression combined with bone grafting in the treatment of early osteonecrosis of femoral head / 中华骨科杂志

Objective:To explore the clinical effect of robot-assisted core decompression combined with bone grafting in the treatment of early-stage osteonecrosis of femoral head.Methods:The data of 49 patients (84 hips) who attended the Department of Orthopedics and Joint Surgery of the Second Affiliated Hospital of Xi'an Jiaotong University from August 2019 to February 2021 were retrospectively analyzed. All the patients suffering Association Research Circulation Osseous (ARCO) II stage of osteonecrosis of femoral head underwent core decompression and bone grafting. Among the patients undergoing surgery, 30 patients (54 hips), including 19 males and 11 females, aged 44.3±5.4 years (range, 21 to 59 years) were treated with conventional surgical methods, and 19 patients (30 hips), including 12 males and 7 females, aged 41.4±7.2 years (range, 20 to 58 years), were assisted by the orthopedic robot navigation system. All operations were performed by the same operator. All patients were informed of the conventional and robotic surgical options by the surgeon at admission, and the patients made the decision. The baseline data of the two groups of patients, the time of unilateral operation, the number of unilateral X-ray fluoroscopy, the Harris hip score at the last follow-up after surgery, the visual analog score (VAS), and the collapse rate at the last follow-up were collected and compared.Results:A total of 41 patients (70 hips) were followed up, including 24 cases (42 hips) in the conventional surgery group and 17 cases in the robot-assisted group (28 hips). The average follow-up time of all cases was 14.6±4.8 months (range, 3 to 21 months). At the last follow-up, a total of 13 patients (13 hips) suffered femoral head surface collapse, including 11 patients in the conventional surgery group (11 hips) and 2 patients in the robot-assisted group (2 hips). The rate of femoral head collapse between the two groups had statistical difference ( P=0.045). The average operation time of unilateral hip in the conventional operation group was 21.3±5.4 min, and 16.8±3.3 min in the robot-assisted group, with significant difference ( t=3.94, P<0.001). The number of X-ray fluoroscopy of unilateral hip in the conventional operation group was 14.4±3.8 times, and 9.6±2.1 times in the robot-assisted group, with significant difference ( t=6.08, P<0.001). The Harris hip score before surgery in the conventional surgery group was 68.4±4.5 points, and 85.1±3.8 points at the last follow-up, while the preoperative Harris hip score of the robot-assisted surgery group was 67.2±3.9 points, and 86.5±4.4 points at the last follow-up. The Harris hip scores at the last follow-up of the two groups were significantly different from those before the operation, but there was no difference between the two groups after surgery ( t=1.09, P=0.283). The preoperative VAS of the conventional surgery group was 4.8±1.7 points, and 1.7±0.8 points at the last follow-up. The preoperative VAS of the robot-assisted surgery group was 5.1±1.5 points, and 0.9±0.3 points at the last follow-up. Τhere were significant differences between the two groups regarding the VAS in the last follow-up ( t=3.92, P<0.001). Conclusion:Core decompression combined with bone grafting have a definite effect in the treatment of osteonecrosis of ARCO II stage of osteonecrosis of femoral head. Compared with conventional surgery, robot-assisted surgery can achieve better short-term results and head preservation rate.

Analysis of influence of MR signs on Harris score in ARCO stages 2-4 femoral head necrosis / 中国骨伤

OBJECTIVE@#To analysis and determine MR signs of Harris score ARCO stages 2-4 in osteonecrosis of femoral head (ONFH).@*METHODS@#Thirty-four patients with ONFH of ARCO stages 2 to 4 who underwent routine MR, T2 mapping, 3D-SPACE sequence examination and Harris score were retrospectively collected from January 2019 to June 2020, and 3 patients were excluded, and 31 patients were finally included, including 23 males and 8 females, aged from 18 to 62 years old with an average of(40.0±10.8) years old. Among them 21 patients with bilateral femoral head necrosis, totally 52 cases, including 17 with ARCO stage 2 patients, 24 ARCO stage 3, and 11 ARCO stage 4. MR imaging signs (femoral head collapse depth, ONFH index, bone marrow edema, hyperplasia, grade and T2 value of cartilage injury, and joint effusion) were scored and measured on the picture archiving and communication system (PACS) workstation, and the cartilage quantitative parameter T2 value was calculated and measured on Siemens postprocessing workstation. Pearson correlation analysis was used to evaluate the correlation between various MR signs and Harris score, and then multiple linear regression analysis was used to examine impact of MR signs on Harris hip score.@*RESULTS@#Femoral head collapse depth(r=-0.563, P=0.000), grade of cartilage injury(r=-0.500, P=0.000), and joint effusion (r=-0.535, P=0.000) were negatively correlated with Harris score by Pearson correlation analysis. Multiple linear regression analysis showed that joint effusion(β=-6.198, P=0.001) and femoral head collapse depth(β=-4.085, P=0.014) had a significant negative impact on Harris hip score.@*CONCLUSION@#Femoral head collapse depth and joint effusion both had significant negative relationship with Harris hip score. It is recommended to routinely evaluate femoral head collapse depth and joint effusion quantitatively and gradedly, so as to efficiently and accurately assist clinical diagnosis and treatment.

Femoral head necrosis rate and risk factors after internal fixation of femoral neck fracture:a Meta-analysis / 中国骨伤

OBJECTIVE@#To study the incidence and risk factors of osteonecrosis of the femoral head (ONFH) after internal fixation in adult patients with femoral neck fracture (FNF) after 2000, and identify high-risk population of ONFH.@*METHODS@#PubMed, Medline, The Cochrane Library, CNKI, Wanfang and VIP Database were searched to collect all the literatures on ONFH and related risk factors after internal fixation of FNF from January 1th 2000 to July 1th 2020. Study extraction was performed according to inclusion and exclusion criteria. Endnote X9 and Excel 2019 were used for literatures extraction, management and data entry, and R Studio 3.6.5 software was used for Meta-analysis. Subgroup analysis, sensitivity analysis and publication bias detection were used to explore the sources of heterogeneity and the reliability of the evaluation results.@*RESULTS@#A total of 16 studies with 5521 patients were included. Meta-analysis showed that the incidence of ONFH after internal fixation for adult FNF was 14.5% [95% CI(0.126-0.165)]. Fracture displacement[OR=0.27, 95%CI(0.21-0.35)] and reduction quality [OR=0.15, 95%CI(0.09-0.27)] were related risk factors for ONFH. The results of subgroup rate analysis showed that the non-displaced fracture necrosis rate was 6.2%[95%CI(0.051-0.077)] and the displaced fracture necrosis rate was 20.4% [95%CI(0.166-0.249)];the good reduction fracture necrosis rate was 8.3%[95%CI(0.072-0.095)] and the poor reduction fracture necrosis rate was 35.5%[95%CI(0.233-0.500)]. The included literatures have good consistency and no publication bias.@*CONCLUSION@#After 2000, the total incidence of ONFH after internal fixation of adult FNF has decreased, while the necrosis rates of patients with displaced fracture and poor reduction are still at a high level. The interval between injury and surgery was not analyzed in this study because of the inconstant division in the original literature.

Risk factors for avascular necorosis after closed reduction of developmental dysplasia of the hips / 中华骨科杂志

Objective:To analyze the risk factors of avascular necrosis (AVN) after closed reduction and spcia casting in treating developmental dysplaisa of the hip (DDH).Methods:The patients with DDH who received closed reduction in our department from January 2016 to December 2017 were retrospectively reviewed. The inclusion criteria included aged at reduction ≥6 months, achieving successful reduction, having complete data with more than 2 years follow-up. A total of 48 cases with 54 hips were included in the present study. Among them, there were 2 males and 46 females, 41 unilateral hips and 13 bilateral hips. The mean age at closed reduction was 16.4±3.8 months (range 6-24 months). The mean follow-up duration was 2.9±1.8 years (range 2.3-4.1 years). Closed reduction was conducted under general anesthesia followed with a spcia cast immobilization. The abduction angle of the cast was recorded. The stability of reduction was evaluated by Ramsey safety zone. The maximum abduction and re-dislocation abduction were recorded. The quality of reduction was evaluated by the medial gap and femoral head coverage on intraoperative arthrography and post-reduction MRI. AVN was diagnosed according to Salter criteria. The risk factors of AVN were analyzed by univariate and binary logistic regression analysis.Results:AVN occurred in 12 hips (22.2%) of 54 hips. International Hip Dysplasia Institute (IHDI) grade and the difference between maximum abduction and cast abduction (Max-Cast abduction) were related to the occurrence of AVN in univariate analysis. The incidence of AVN in hips of IHDI grade 4 (42.9%, 9/21) was significantly higher than that in hips of IHDI grade 3 (9.7%, 3/31) (χ 2=6.007, P=0.018). However, the hips of IHDI grade 3 and 2 (0%, 0/2) presented a similar incidence of AVN (χ 2=0.000, P=1.000). The Max-Cast abduction was -0.7°±5.9° in the AVN group and 6.1°±7.6° in the AVN group ( t=2.125, P=0.038). Finally, IHDI grade ( OR=8.256, P=0.015) and Max-Cast abduction ( OR=0.832, P=0.047) were both independent factors of AVN in multivariate analysis. Conclusion:Most of the hips with AVN are IHDI grade 4 after closed reduction for DDH. The abduction angle in a spica cast could not be significantly related to the occurrence of AVN. However, the risk of AVN might be increased when the cast abduction is close to or beyond the maximum abduction. Safe abduction in the cast should be 5 to 10 degrees less than maximum abduction at least.

Mechanism of yougui yin for steroid-induced femoral head necrosis based on network pharmacology / 中国组织工程研究

BACKGROUND: Existing cell experiments, animal experiments and clinical experiments have found that Yougui Yin can play a positive role in steroid-induced femoral head necrosis, but the specific pharmacological mechanism of Yougui Yin is not described. OBJECTIVE: To explore the mechanism of Yougui Yin in the treatment of steroid-induced femoral head necrosis based on network pharmacology, and to provide a theoretical basis for the clinical application of Yougui Yin in the treatment of steroid-induced femoral head necrosis. METHODS: The Chinese Medicine Computing System Pharmacology Analysis Platform (TCMSP) was used, with oral bioavailability and drug-like properties as the limiting conditions, to retrieve the main active ingredients of six kinds of traditional Chinese medicines including Monkshood, Cinnamon, Rehmannia glutinosa, Cornus officinalis, stir-baked rhizoma dioscoreae, wolfberry in Yougui Yin and predict key target genes. Target genes related to steroid-induced femoral head necrosis were searched in OMIM and GeneCards databases, and the intersection target genes of Yougui Yin and steroid-induced femoral head necrosis were obtained through R language, followed by drawing the Wayne diagram. Using Cytoscape 3.6.1 software, we drew a “component-disease-target” Chinese medicine regulatory network, and then established a protein-protein interaction network with the help of the STRING platform. Finally, the R language and Bioconductor platform were used to perform gene ontology enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis on the intersection genes. RESULTS AND CONCLUSION: There were 43 main effective components in Yougui Yin, including quercetin, glycotein, diosgenin, karanjin, stigmasterol, etc. and 102 key target genes, including ESR1, AKT1, NCOA1, PTGS1, JUN, etc. Gene ontology enrichment analysis revealed 137 molecular functions, 2 119 biological processes and 41 cell components. KEGG pathway analysis yielded 153 signal pathways. To conclude, Yougui Yin may play an anti-osteoporosis and anti-inflammatory role by regulating steroid hormone receptor, phosphatase binding and other molecular functions, participating in biological processes such as active oxygen metabolism and steroid hormone response, affecting cell composition such as membrane raft and RNA polymerase II transcription factor complex, so as to treat steroid-induced femoral head necrosis with the help of endocrine resistance and other signal pathways.

Effect of yougui decoction on autophagy and fate of bone marrow mesenchymal stem cells in rats with glucocorticoid-associated femoral head necrosis / 中国组织工程研究

BACKGROUND: Yougui Decoction is an empirical prescription for the treatment of glucocorticoid-associated femoral head necrosis. Literature has shown that the pathogenesis of glucocorticoid-associated femoral head necrosis is associated with glucocorticoid-induced autophagy down-regulation and fate change in bone marrow mesenchymal stem cells. OBJECTIVE: To investigate the effect of Yougui Decoction on autophagy and fate of bone marrow mesenchymal stem cells in model rats of glucocorticoid-associated femoral head necrosis. METHODS: We used Escherichia coli endotoxin combined with high-dose dexamethasone to make the rat models of early femoral head necrosis. Forty SHR rats were randomly divided into five groups: blank control group, model group, high-dose Yougui Decoction group, medium-dose Yougui Decoction group and low-dose Yougui Decoction group. After 6 weeks of intervention, medullary cavity tissue of the rat proximal femur was taken for hematoxylin-eosin staining and immunohistochemical staining of autophagy proteins LC3 II, P53 and beclin-1. After culture and induction of bone marrow mesenchymal stem cells, alizarin red staining, bone alkaline phosphatase quantification, oil red staining and MTT determination were performed and western blot assay was used to quantitatively measure the expression of LC3 II, P53 and beclin-1 proteins. RESULTS AND CONCLUSION: (1) Immunohistochemistry and western blot assay results showed that Yougui Decoction significantly increased autophagy protein LC3 II, P53 and beclin 1 expression in a dose-dependent manner. (2) Alizarin red staining, oil red staining and bone alkaline phosphatase quantification suggested that Yougui Decoction could significantly interfere with the fate of bone marrow mesenchymal stem cells, up-regulate their osteogenic differentiation and down-regulate their adipogenic differentiation in a dose-dependent manner. (3) MTT results suggested that Yougui Decoction significantly improved the proliferation ability of bone marrow mesenchymal stem cells, but had no significant differences in different doses. (4) To conclude, Yougui Decoction can significantly improve the autophagy expression, change the cell fate, up-regulate osteogenic differentiation and down-regulate adipogenic differentiation of bone marrow mesenchymal stem cells in the rat models of glucocorticoid-associated femoral head necrosis, which provides certain basis for elucidating the mechanism of Yougui Decoction in treating glucocorticoid-associated femoral head necrosis.

Application of fibular flap with partial continuous periosteum and cortex in hip preservation surgery for femoral head necrosis / 中华显微外科杂志

Objective:To investigate the short-term clinical effect of using fibular flap with preserving the continuity of fibula in hip preservation surgery for femoral head necrosis.Methods:From September, 2017 to November, 2020, 13 cases of femoral head necrosis were repaired with fibular flap. The fibular flaps were cut with an improved method for preserving the continuity of the fibular cortex, and the donor sites were sutured directly. The fibuls were inserted into the femoral heads with single or double segment folding support. Autogenous iliac crest combined with platelet-rich plasma(PRP) was used for impaction of bone grafting in femoral head, and the fibular flaps were anastomosed with 1 artery and 2 veins. All follow-up data were obtained, including bone union by X-ray and CT as well as the functional recovery of the hip joint and donor site. Statistical analysis was performed. P<0.05 was considered statistically significant. Results:The followed-up time ranged from 6 to 23 months. The fibular bones were significantly thicker and the incisions healed well at the donor sites. There was neither abnormal sensation in toes, dorsal foot, and lateral of the leg, nor significant influence on foot function. The hip joint activities were normal. The outcome was proved to be remarkable according to the Harris score(from 58.9±10.6 points before surgery to 81.7±10.6 points after surgery), the difference was statistically significant ( P<0.05) . Conclusion:The method of the improved fibular flap in hip preservation surgery is beneficial to the repair and reconstruction of the necrotic femoral head since the donor area is less traumatic, and a satisfactory clinical effect can be obtained.

Short term effect of double channel decompression and bone grafting via greater trochanter combined with allograft fibula propping in the treatment of femoral head necrosis / 中国骨伤

OBJECTIVE@#To investigate the short-term clinical effect of double channel decompression and bone grafting through the greater trochanter combined with allograft fibula propping in the treatment of osteonecrosis of femoral head (ONFH).@*METHODS@#Twenty two patients (23 hips) with osteonecrosis of the femoral head were included from November 2017 to February 2019. According to Association Research Cirulation Osseous(ARCO) staging, there were 13 hips at stageⅡgroup, aged from 20 to 48 years old with an average of(32.5±8.5)years old;10 hips at stageⅢgroup, aged from 18 to 45 years old with an average of(32.7±8.6) years old. A single approach through the greater trochanterwas used for decompression, bone grafting and fibula support. Harris scoring system was used to evaluate the function of hip joint before and after implantation, and the anteroposterior and lateral X-ray films of hip joint were taken at 3, 6, 12 and 18 months after implantation to observe and analyze the progress of femoral head necrosis and regeneration.@*RESULTS@#All patients were followed up, and the duration ranged from 12 to 18 months with an average of (14.6±2.1) months. Harris score of stageⅡand stageⅢpatients increased from 73.2± 5.5 and 66.5±3.4 to 87.6±8.7(@*CONCLUSION@#The effect of double trochanteric decompression and bone grafting combined with fibular allograft propping in the treatment of early and middle stage avascular necrosis of the femoral head is good, especially suitable for young and middle aged patients with ARCOⅡstage avascular necrosis of the femoral head.