Optimization of Traction Magnetic Resonance Imaging to Improve Visibility of the Elbow Cartilage.

We previously reported that elbow magnetic resonance imaging (MRI) with 7 kg traction increases the joint space width of the radiocapitellar joint and improves articular cartilage visibility without arthrography. However, the optimal traction weight remains unclear. We assessed the effects of different traction weights on elbow MRI in 30 healthy volunteers. Elbow MRI was performed without traction and with 3, 5, and 7 kg axial tractions. The joint space width, humeral articular cartilage outline visibility, and intraprocedural pain/discomfort were evaluated. The joint and cartilage parameters were measured at the radiocapitellar joint and the lateral and medial thirds of the ulnohumeral joint. At the radiocapitellar joint, the joint space width increased significantly with traction. The cartilage outline visibility significantly increased with traction, with no significant differences among the traction weights. No significant result was observed at the lateral and medial thirds of the ulnohumeral joint. Pain and discomfort significantly increased as we used heavier traction weights. Elbow MRI with 3 kg traction showed sufficient effects similar to those observed with 7 kg traction with minimal pain and discomfort. There was no difference in the effect of traction between male and female participants. This procedure may enable enhanced visualization of intra-articular elbow injuries.

Analyzing Chronological Change in Postoperative Magnetic Resonance Imaging Results in Patients With Kienböck's Disease by Using an Original Grading System.

Background and objective Signal changes in MRI for Kienböck's disease have only been qualitatively assessed so far. In light of this, we proposed a new grading system for quantitative analysis with an ordinal scale. Methods The study included 31 patients (17 men, 14 women) with Kienböck's disease. By referring to Nakamura's MRI grading system, we devised a grading system with five grades (Grades 1-5) using proton density-weighted (PDW) coronal images with respect to the signal intensity of the lunate. All cases were examined by using the MRI grading system by three hand surgeons, both preoperatively and postoperatively. We evaluated the inter-rater reliability of our grading system by using the interclass correlation coefficient. After surgery, we implemented annual MRI evaluation for as long as possible and quantitatively assessed changes in MRI grades. We also investigated the correlation between postoperative MRI grades, Mayo Wrist Scores (MWS), and age at the surgery by using Pearson's coefficient. Results The MRI evaluation was performed 2-15 years after surgery. The reliability of our grading system was high; inter-rater interclass correlation coefficients were 0.783 (examiners 1-2), 0.780 (examiners 1-3), and 0.825 (examiners 2-3), representing a substantial agreement. The correlation coefficient between the MRI grade and MWS was -0.31, suggesting a mild negative correlation; postoperative MRI grade also correlated with age at surgery (Pearson's coefficient: 0.447). Conclusions Our proposed MRI grading system has high reliability and could be used to assess the regeneration of a necrotic lunate for quantitative analysis on an ordinal scale. Improvements were observed one to four years postoperatively, demonstrating a mild correlation with the clinical results.

Reconstruction of hook grip function of the fingers in patients with traumatic brachial plexus injury.

We described a reconstruction method for restoring hook grip function of the fingers in patients with total brachial plexus injury. The paralysed latissimus dorsi muscle was transferred to the upper limb as a pedicle flap and sutured to the flexor digitorum profundus tendons. The muscle was then reanimated with two intercostal donor nerves to the thoraco-dorsal nerve. Fourteen young adult patients (mean 23 years, range 17 to 32 years) with traumatic brachial plexus injury who underwent reconstruction using this technique from 2000 to 2019. After mean follow-up of 65 months (range 20 to 170), finger flexion of strength greater than or equal to M3 was achieved in 10 of the 14 patients. The mean weight that could be lifted using a hook grip was 2.6 kg, and that which could be lifted with both hands was 4.1 kg. The intercostal nerve-innervated latissimus dorsi muscle transfer can provide useful hook grip hand function without the need to sacrifice donor vessels or healthy muscles.Level of evidence: IV.

Feasibility and Safety of a Novel Leg Exercise Apparatus for Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty of the Lower Extremities-A Pilot Study.

Venous thromboembolism (VTE) is a severe complication in orthopedic surgeries. Herein, we developed a novel leg exercise apparatus (LEX) to encourage postoperative limb movement in bedridden patients to prevent VTE. We aimed to evaluate its feasibility and safety in individuals at risk of VTE. Twenty patients (four men, 16 women) who underwent total joint arthroplasty in the lower extremity were enrolled in this prospective study. Exercise using the LEX was performed for 5 min at 30 cycles/min, four times/day during postoperative days 1-7. Clinical assessments included the evaluation of vital signs, venous ultrasonography, and blood tests within seven days postoperatively, and adverse events (pulmonary embolism and cerebral hemorrhage) were monitored. Overall, 16/20 (80%) patients completed the 7-day exercise regimen. There were no cases of severe adverse events, changes in vital signs, or lower-extremity deep vein thrombosis in patients who performed exercises with the LEX. Thus, the results of this pilot study show that this novel apparatus may be a safe and feasible tool for VTE prophylaxis after joint arthroplasty of the lower extremities.

Does the Radius Contain Bone Marrow Mesenchymal Stem Cells?-A Comparison between Cells of the Iliac Crest and Radius in Kienböck's Disease.

Background: Numerous studies have indicated the presence of mesenchymal stem cells (MSCs) in the bone marrow aspirated from the vertebral body, distal femur, proximal tibia, humeral head, sternum, and iliac crest. However, their presence has not been reported in the radius thus far. In this study, we aimed to compare the number of MSCs in bone marrow aspirated from radius and iliac crest in patients with Kienböck's disease. Furthermore, we examined the association between the number of MSCs in the bone marrow and patient age. Methods: A total of 17 patients were recruited. Owing to difficulties in obtaining samples for 5 cases, only 12 cases were included. Hematological analyses and fibroblastic colony-forming unit (CFU-F) assay were performed using bone marrow samples aspirated from the radius (group R), the first sample aspirated from the iliac crest (group I-1), and the second sample aspirated from the iliac crest (group I-2). The CFU-F numbers among the three groups were compared using Mann-Whitney U-test. Pearson's correlation coefficient was calculated to evaluate the association between the CFU-F numbers and patient age. Results: The average numbers of CFU-Fs/ml in the bone marrow samples from the R, I-1, and I-2 groups were 3.4, 57.3, and 13.7, respectively. The CFU-F number in Group I-1 was significantly higher than that in the other two groups; the CFU-F number was lower in group R than in group I-2. The correlation coefficients were -0.168, 0.166, and 0.036 for samples from groups R, I-1, and I-2, respectively. No significant association between the CFU-F numbers and patient age was observed. Conclusions: The presence of MSCs in the radius was indicated by CFU-Fs in patients with Kienböck's disease. The number of CFU-Fs was lower in the radius than in the iliac crest; the CFU-F number was not associated with patient age.

Effect of elbow MRI with axial traction on articular cartilage visibility-a feasibility study.

OBJECTIVE: Accurate evaluation of the articular cartilage of the elbow using MRI is sometimes challenging because of its anatomical complexity and relatively small size. Moreover, the articular cartilage of the humerus is in close contact with the opposing cartilage surfaces. Magnetic resonance arthrography with traction was reported to resolve this issue; however, less invasive methods are desirable. This study aimed to assess the effect of MRI with axial traction (without arthrography) on joint space widening and cartilage outline visibility of the elbow. MATERIALS AND METHODS: We enrolled 10 volunteers (female = 1; mean age, 36.7 ± 8.6; range 28-56) and performed MRI with and without axial traction on the elbow. Joint space widths were measured, and the humeral articular cartilage outline visibility was evaluated at the radiocapitellar joint and lateral one-third and medial one-third of the ulnohumeral joints. Measurements were compared using the Wilcoxon signed-rank test. Significance was set at p < 0.05. Volunteers scored pain and discomfort during MRI with traction using the visual analog scale in a questionnaire format. RESULTS: Traction significantly increased joint space width at the radiocapitellar joint. Humeral articular cartilage outline visibility also significantly improved at the radiocapitellar joint. Pain and discomfort scores during traction MRI were low. CONCLUSION: MRI of the elbow with traction widens joint space and enables better articular cartilage visibility at the radiocapitellar joint. Anatomical features of the elbow might have affected these results. Therefore, it would be safe and useful for evaluating elbow injuries involving articular cartilage lesions.

Osteoarticular lesion in xanthoma disseminatum treated with total hip arthroplasty: a case report.

INTRODUCTION: Xanthoma disseminatum is a very rare disease classified as a benign non-Langerhans cell histiocytosis, which is rarely associated with osteoarticular lesions. There is only a report of tumor abrasion during treatment of osteoarticular lesions of this disease, artificial joint replacement has not been reported. We describe a patient in whom bilateral total joint replacement was performed for disseminated xanthoma lesions of the hip joints. CASE PRESENTATION: A 34-year-old Japanese woman had a chief complaint of bilateral coxalgia. She had been diagnosed as having disseminated xanthoma. Radiographs showed numerous 5-mm radiolucent bands that resembled worm-eaten tracks in the lower part of the femoral heads adjacent to the joint surface. In addition, short tau inversion recovery imaging scans showed high-intensity areas from the femoral head to the neck in both femurs, suggesting bone marrow edema. Total hip arthroplasty was performed for hip arthrosis on both hip joints caused by disseminated xanthoma. Deflection of the implants was a concern from the early stages postoperatively, but both the imaging and clinical findings have been satisfactory for 4 years of follow-up. CONCLUSIONS: A very unusual hip joint lesion of xanthoma disseminatum was replaced with a total artificial joint replacement, and the course over 4 years was good. Our patient's course will continue to be followed carefully.

For how long do denervated muscles in children retain the ability to regenerate?: Restoration of elbow flexion and shoulder function by partial nerve transfer in a child with long-standing poliomyelitis-like paralysis.

BACKGROUND: In infant poliomyelitis or poliomyelitis-like paresis, there has been no means of treating residual paralysis and the policy has been to wait until an affected infant has grown sufficiently to enable tendon transfer or arthrodesis. However, recent reports have described relatively good results for early surgical intervention in the form of nerve transfer. METHODS: In a 4-year and 6-month-old child we transferred a partial ulnar nerve for elbow flexor reconstruction even 3 years and 10 months after the onset of poliomyelitis-like palsy and also transferred partial accessory and radial nerves for shoulder function restoration 6 months after the first operation. RESULTS: Elbow flexor restored M4 on the British Medical Research Council scale. The shoulder subluxation resolved, however, the strengths of the deltoid and infraspinatus remained almost M1. At the most recent clinical examination, the patient was 18 years old and the active range of motion of patient's left elbow was 0°-125°, and those of the whole shoulder girdle were abduction 35°, flexion 60°, extension 30° and external rotation 0°. CONCLUSIONS: The outcomes we achieved may support partial nerve transfer techniques as viable treatment options for persistent long-standing motor deficits following poliomyelitis-like palsy in children. However, we recommend performing partial nerve transfer as early as possible after recovery from flaccid paralysis and also use of nerves that derive from narrow spinal cord segments. After denervation, children's neuromuscular systems seem to have the ability to regenerate after a much longer period than has generally been believed. This speculation is based on only a single case report; thus, more experience is needed before this generalization can confidently be made.

Robotic rehabilitation training with a newly developed upper limb single-joint Hybrid Assistive Limb (HAL-SJ) for elbow flexor reconstruction after brachial plexus injury: A report of two cases.

This study aimed to evaluate the effectiveness and safety of using the upper limb single-joint Hybrid Assistive Limb (upper limb HAL-SJ) during elbow flexion training following elbow flexor reconstruction for brachial plexus injury (BPI). We present the cases of two patients in whom the upper limb HAL-SJ was implemented 5 and 7 months postoperatively following elbow flexor reconstruction for BPI. They underwent elbow flexor reconstruction with intercostal nerve crossing-to-musculocutaneous nerve (ICN-MCN crossing) after BPI. Postoperative training using the upper limb HAL-SJ was started from the Medical Research Council (MRC) grade 1 elbow flexion power to MRC grade 3 once every week or every 2 weeks. Both patients could implement elbow training using the upper limb HAL-SJ even in MRC grade 1 of their elbow flexion power. Training with the upper limb HAL-SJ was performed safely and effectively in two patients with elbow flexor reconstruction with ICN crossing after BPI.

Trapezium Fracture Associated with Thumb Carpometacarpal Joint Dislocation: A Report of Three Cases and Literature Review.

Isolated trapezium fracture in combination with thumb carpometacarpal (CMC) joint dislocation is extremely rare, and no treatment consensus exists. Herein, we report 3 successfully treated cases of isolated trapezium fracture with thumb CMC joint dislocation. While good short-term results have been reported in the literature, the possibility of substantial ligament injuries that can lead to future instability of the thumb CMC joint must be noted. In order to obtain an excellent long-term clinical result, we propose the consideration of the anatomical repair of the CMC joint in terms of both bony and ligamentous structures in cases where instability remains after fracture fixation.

Subacute Urinary Retention due to a Subpubic Cartilaginous Cyst Treated with Surgical Resection and Internal Fixation: A Case Report and Review of the Literature.

A subpubic cartilaginous cyst is a rare mass lesion derived from the pubic symphysis, which can cause acute or subacute urinary retention. We report a case of a subpubic cartilaginous cyst in a 62-year-old woman that caused lower abdominal pain and subacute urinary retention, requiring surgical resection. On physical examination, a hard, flexible, nontender mass, 4 cm in diameter, was palpable along the lower border of the pubic bone, extending to the perineum. Magnetic resonance imaging revealed a clearly distinct (3.8 cm × 3.8 cm × 7.2 cm) mass on the midpelvic side of the pelvis, centered on the pubic joint. We proceeded with en bloc resection of the mass, including a resection margin of 1 cm on either side. The bony defect was fixed with a locking plate. On pathological assessment, the mass was diagnosed as a subpubic cartilaginous cyst arising from the cartilage of the pubic symphysis. No tumor recurrence was identified over a 4-year follow-up. Based on our experience, we propose that en bloc resection of the mass, including a wider resection centered on the pubic symphysis, with internal fixation, is a possible treatment for a subpubic cartilaginous cystic mass lesion.

A novel exercise device for venous thromboembolism prophylaxis improves venous flow in bed versus ankle movement exercises in healthy volunteers.

PURPOSE: Venous thromboembolism prophylaxis is crucial. To facilitate active ankle movement in postoperative and bedridden patients, we developed a novel leg exercise apparatus (LEX). We investigated the effect of the LEX by comparing increases in lower extremity venous flow during different modes of exercise using the LEX. METHODS: In eight healthy participants, we measured venous flow volume and velocity in the femoral vein using duplex ultrasonography at 1, 10, 20, and 30 min after completing three modes of 1-min LEX exercises. The exercises involved (1) rapid single motion (ankle dorsi-plantar flexion; 60 cycles/min); (2) slow single motion (30 cycles/min); and (3) slow combined leg motion. RESULTS: Flow volumes after modes 1, 2, and 3 were 1.63-, 1.39-, and 1.53-fold above baseline at 30 min, respectively. Short periods of rapid single motion, with the LEX, improved postexercise lower extremity venous flow volumes at 30 min and mean venous flow velocity at 20 min, compared to slow single motion exercise. Even at slow speeds, combined-motion improved flow volume compared to single motion. CONCLUSION: Short periods of rapid single motion exercise, with the LEX, improved postexercise venous flow volumes in the lower extremities at 30 min and mean venous flow velocity at 20 min. These effects were greater than those produced by slow single motion exercises. However, even at slow speeds, combined-motion exercises improved flow volume compared to single motion. Therefore, LEX may prove effective at preventing thromboembolism in postoperative and bedridden patients.

Disruption of Flexor Tendon after Intrasheath Triamcinolone Acetonide Injection for Trigger Digits: Two Case Reports.

We experienced two cases of flexor tendons rupture after triamcinolone acetate (TA) injection for trigger finger. A 45-year-old man underwent injection of 40 mg of TA and 1 mL of 1% lidocaine solution into his little finger. While playing golf 3 months after the injection, he heard a popping sound, and was unable to flex it. A 57-year-old female nurse had undergone injection of 40 mg of TA and 1 mL of 1% lidocaine solution into her thumb twice at a 2-month interval. Two months after the second injection, she was unable to flex it. Both cases had high concentrated TA injection at trigger digits. The present and previous cases illustrate that when TA is injected into trigger digits, the dose should be low, the safety interval should be long, and refuse injection into the tendon proper.

The relationship between preoperative needle electromyography findings and muscle power restoration after surgery in severe carpal tunnel syndrome patients.

PURPOSE: Needle electromyography provides essential information about the functional aspects of the muscle. But little attention has been given in the literature to needle electromyography examinations in carpal tunnel syndrome. We examined the relationship between preoperative needle electromyography findings and functional recovery of the abductor pollicis brevis (APB) muscle in severe carpal tunnel syndrome patients. METHODS: The subjects of this study were 49 patients, 58 hands, who fit the following 5 criteria: (1) idiopathic carpal tunnel syndrome; (2) pre-op MMT grade of the APB muscle was M0 or M1; (3) APB-CMAP (compound muscle action potential) was not evoked in a median nerve conduction study; (4) needle electromyography of the APB muscle had been done; (5) underwent carpal tunnel release only. The patients were divided into two groups according to the results of pre-op needle electromyography: voluntary motor unit potential of the APB muscle was evoked [MUP(+) group]or not [MUP(-) group]. We evaluated APB muscle strength at one year after surgery, and patient satisfaction and functional evaluations (CTSI-FS) at more than one year after. RESULTS: The APB muscle recovery rate to M3 or higher was 100% in the MUP(+) group, and 57% in the MUP(-) group. Patient satisfaction was also high and functional recovery was sufficient in the MUP(+) group. No patients requested a second opponensplasty. CONCLUSION: Our findings suggest that post-op restoration of thumb function relates to whether or not the MUP ofthe APB muscle is evoked. Single-stage opponensplasty may be unnecessary if the MUP of the APB muscle is; evoked. Needle electromyography is therefore useful in consideration for opponensplasty. LEVEL OF EVIDENCE: Level Ⅲ, case-control study.

2. The Effect of Combined Therapy, Percutaneous Autologous Concentrated Bone Marrow Grafting and Low-Intensity Pulsed Ultrasound (LIPUS), on the Treatment of Non-Unions.

We discuss the effect of combined therapy of percutaneous autologous concentrated bone graft and LIPUS on complex non-union treatment. Seventeen of 27 treated patients who had received the therapy at least 1 year before were discussed (10 femurs, 5 tibiae, 1 humerus, and 1 ulna). The average age of the patients was 40.7, and atrophic degeneration was observed in all cases. After 12 months of treatment, bone union was recognized in 76% in all cases, and in 87% of lower long bones. It was reported that LIPUS was effective at improving blood flow, accelerating cytokines which induce angiogenesis, promoting the transport of nutrition and enzymes to living cells, developing the differentiation of osteoblast from mesenchymal stem cells (MSC), inhibiting the differentiation and development of osteoclast, and promoting endochondral ossification. In this study, all patients had been treated with LIPUS for more than 3 months before the grafting was conducted, but the bone union seemed to stop. It was thought that this combined therapy provided a bone marrow cell growth factor sufficient to enable new bone formation to re-start bone union, and then LIPUS worked effectively to promote the initial differentiation, contributing to new bone formation. This combination therapy-less invasive, safe, and low cost-was considered one useful treatment option for non-union.

Lipofibromatous Hamartoma of the Median and Ulnar Nerves at the Ipsilateral Wrist.

Lipofibromatous hamartoma (LFH) is a rare condition of the peripheral nerves that typically affects the median nerve. To the best of our knowledge, this is the first report of LFH of both, the median and ulnar nerves, at the wrist of a 63-year-old female patient. The patient presented to our hospital with a 40-year history of pain, numbness, and dysesthesia affecting all fingers of her left hand. Atrophy of the thenar muscles and the first dorsal interosseous was observed upon physical examination. Imaging studies and a surgery revealed that the patient's median and ulnar nerves were significantly enlarged, confirming the LFH diagnosis. The patient's dysesthesia and numbness improved after Carpal tunnel and Guyon canal release, and her pinch ability improved after opponensplasty. LFH has been known to be solitary, typically affecting median nerve, but it must be noted that the tumor may affect multiple nerves like in our case.

The use of a novel in-bed active Leg Exercise Apparatus (LEX) for increasing venous blood flow.

OBJECTIVE: The incidence of pulmonary embolism (PE) and leg deep vein thrombosis (DVT) has increased in recent years in association with aging and an increase in the number of bedridden individuals. We developed an active in-bed leg exercise apparatus labeled the Leg Exercise Apparatus (LEX) for DVT prevention. We compared the effect of leg exercises performed using the LEX to conventional active ankle exercises on increased blood flow. MATERIALS & METHODS: The subjects were eight healthy adult volunteers [five men and three women, aged 20-34 (mean 27.0) years]. Subjects performed two types of exercise; exercise 1 consisted of leg exercises using the LEX, while exercise 2 consisted of in-bed active plantar flexion/dorsiflexion exercises without the device. Measurements were taken 1, 5, 10, 20, and 30 minutes after exercise including common femoral vein blood flow, mean blood flow velocity, maximum blood flow velocity, and vessel diameter using Doppler ultrasound. Statistical procedures included timed measurement data analysis using a linear mixed model. A Bonferroni correction was used for multiple comparisons. RESULTS: Compared to resting levels, blood flow reached a maximum value 1 minute after exercise for both exercise types, with a significantly greater increase after exercise 1 (1.76-fold increase) compared to exercise 2 (1.44-fold increase) (p = 0.005). There was a significant difference (p = 0.03) between the two exercises for all values from 1 minute to 30 minutes following exercise. There was no significant difference between exercises for peak or mean blood flow velocity. Compared to resting levels, blood vessel diameter reached a maximum value of 1.47-fold greater at 5 minutes post-exercise for exercise 1 and a maximum value of 1.21-fold greater at 1 minute post-exercise for exercise 2. CONCLUSIONS: Exercise using the LEX increased lower leg venous blood flow and vessel diameter. We propose that the LEX may serve as a new DVT prevention tool.

Muscle activity in the lower limbs during push-down movement with a new active-exercise apparatus for the leg.

[Purpose] Lower-limb deep vein thrombosis is a complication of orthopedic surgery. A leg-exercise apparatus named "LEX" was developed as a novel active-exercise apparatus for deep vein thrombosis prevention. Muscle activity was evaluated to assess the effectiveness of exercise with LEX in the prevention. [Subjects] Eight healthy volunteers participated in this study. [Methods] Muscle activities were determined through electromyography during exercise with LEX [LEX (+)] and during active ankle movements [LEX (-)]. The end points were peak % maximum voluntary contraction and % integrated electromyogram of rectus femoris, vastus lateralis, biceps femoris, tibialis anterior, gastrocnemius, and soleus. [Results] LEX (+) resulted in higher average values in all muscles except the tibialis anterior. Significant differences were noted in the peak of the biceps femoris and gastrocnemius and in the integrated electromyogram of the rectus femoris, vastus lateralis, gastrocnemius, and soleus. The LEX (+)/LEX (-) ratio of the peak was 2.2 for the biceps femoris and 2.0 for the gastrocnemius . The integrated electromyogram was 1.8 for the gastrocnemius, 1.5 for the rectus femoris, 1.4 for the vastus lateralis, and 1.2 for the soleus. [Conclusion] Higher muscle activity was observed with LEX (+). LEX might be a good tool for increasing lower-limb blood flow and deep vein thrombosis prevention.

The safety and efficacy of combined autologous concentrated bone marrow grafting and low-intensity pulsed ultrasound in the treatment of osteonecrosis of the femoral head.

Osteonecrosis of the femoral head (ONFH) is commonly treated with total hip arthroplasty; however, the disadvantages of this form of treatment, especially in young patients, include the need for revision arthroplasty. Here we describe a novel, combined approach to the treatment of ONFH based on autologous concentrated bone marrow grafting and low-intensity pulsed ultrasound (LIPUS). The 7 male and 7 female patients (mean age: 40 years; 22 hips) underwent autologous concentrated bone marrow grafting followed by 6 months of continuous LIPUS. The mean follow-up period was 26 months. We evaluated site-specific bacterial infection of the grafted bone marrow concentrate microbiologically and site-specific cancer by magnetic resonance imaging 24 months after grafting. All patients were assessed using the visual analogue scale (VAS) for pain and the Japanese Orthopedic Association (JOA) hip score. Clinical and plain radiographic evaluations were performed before grafting and at the most recent follow-up. Computed tomography (CT) scans were obtained before and 12 months after grafting. None of the grafted bone marrow concentrates were infected, and none of the patients developed a tumor at the treatment site. The VAS and JOA scores improved in all patients. Collapse progressed in 8 of the 22 hips, but none required total hip arthroplasty. The mean volume of new bone formation 12 months post-grafting as seen on CT was 1256 mm(3). New bone formation was observed in all patients. Our study demonstrates the safety and efficacy of autologous concentrated bone marrow grafting and LIPUS as a joint-preserving procedure for patients with ONFH.