Osteonecrosis of the femoral head during pregnancy

The correlation between transient osteoporosis of the hip and pregnancy: A review

Transient osteoporosis of the hip is indubitably a comparatively infrequent entity affecting both men and women worldwide. Its occurrence in the course of pregnancy, specifically in the third trimester, and lactation are of paramount concernment. The exact association between transient hip osteoporosis and pregnancy is precarious. Etiology and potential pathophysiological mechanisms behind this correlation are still to be utterly defined. Magnetic resonance imaging is highly regarded as the gold standard imaging method for assiduous assessment of this disorder. Physicians of copious medical specialties should practice scrupulous techniques for early and pertinent diagnosis when pregnant women are presented with persistent hip pain, as differential diagnosis with femoral head avascular necrosis can be exceedingly arduous. Treatment is predominantly conservative with protected weight-bearing and analgesic medication in the first line of management. In terms of prognosis, the disease ordinarily resolves spontaneously after a few months. Further research is required in order to elucidate the ambiguity surrounding the establishment of globally approved diagnosis and treatment guidelines for pregnancy-associated transient hip osteoporosis. This paper aims to accentuate the significance of this particular disorder by providing a succinct review of the existing literature, augmenting clinicians' knowledge about the features of pregnancy-related transient proximal femur osteoporosis.

Hip avascular necrosis in a healthy pregnant woman: A case report and review of literature

Background

Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity.

Case report

We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age.

Discussion

With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called “Pelvic pain syndrome” and transient osteoporosis of the hip.

Conclusion

Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications.

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Corticosteroids and alcohol intake are the most common atraumatic cause of hip osteonecrosis

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Hip and pelvic pain during pregnancy are very frequent and may hide a serious event such as hip avascular necrosis

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Hip avascular necrosis can have disastrous complications if not diagnosed in young pregnant women.

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Having a high index of suspicion in a pregnant woman with hip pain is a must to prevent such complications

Zoledronic acid for the treatment of pregnancy-associated femoral head necrosis: A case report

Introduction

The management of pregnancy-associated femoral necrosis is controversial. Conservative management may eventually lead to hip replacement.

Case

A 40-year-old woman developed necrosis of the left hip during her first pregnancy. Treatment with zoledronic acid three months after delivery resulted in rapid reduction of the necrotic area. The patient's second pregnancy shortly afterwards had no complications. A magnetic resonance scan three years later documented complete resolution.

Conclusion

Femoral head necrosis should be suspected in the differential diagnosis of pain in pregnancy. Zoledronic acid given in the early stages prevented progression to hip arthritis in this case.

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Osteonecrosis of the femoral head must always be taken into account in the differential diagnosis of hip pain in pregnancy.

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Conservative treatment of pregnancy-associated osteonecrosis may lead to hip replacement.

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A prompt treatment may be essential to prevent arthroplasty.

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We report for the first time a case of femoral osteonecrosis treated with zoledronate in a primigravid woman.

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Zoledronic acid proved safe and effective and the outcome persisted throughout the duration of a second pregnancy.

Unusual indication of Cell therapy for hip osteonecrosis after pregnancy

PURPOSE

Osteonecrosis is a rare event during or after pregnancy. Due to the low number of cases, there is no report of long-term results after conservative surgery in this population.

METHOD

From 1992 to 2010, 145 consecutive female patients with unilateral symptomatic (94 stage I and 51 stage II) left hip osteonecrosis (ON) related to pregnancy were treated between 4 and 16 months after delivery with percutaneous mesenchymal stem cell (MSC) injection obtained from bone marrow concentration. The average total number of MSCs (counted as number of colonies forming units-fibroblast) injected in the hip was 185 000 ± 65 000 cells (range 95 000-240 000 cells).

RESULTS

At the most recent follow-up (average 15 years after hip surgery, range 8-25 years), among the 145 hips included in the study, 4 hips (2.7%) had collapsed and were treated with total hip arthroplasty (THA). Thirty-two of the 94 stage I had progressed to stage II; and 4 of the 51 stage II had progressed to stage III and collapse. The other 141 hips (97.3%) were without collapse and pain free. On MRI, as percentage of the volume of the femoral head, the osteonecrosis had decreased from 34.5% pre-operatively to 6% at the most recent follow-up. For women who had other children after treatment, a subsequent pregnancy was not associated with osteonecrosis.

CONCLUSION

Patients with hip osteonecrosis following pregnancy had a low conversion rate to THA when treated early with cell therapy.

Bilateral Osteonecrosis of the Femoral Head During Pregnancy Following Two Corticosteroid Injections: A Case Report and Review of the Literature

Osteonecrosis of the femoral head during pregnancy, or shortly thereafter, is a rare clinical problem. Little is known about pregnancy as an etiological factor for femoral head osteonecrosis with only 40 reported cases in the literature. Furthermore, single or dual dose steroid-induced multifocal osteonecrosis is a controversial topic with only a handful of published cases. We present a case of a 34-year-old female with bilateral femoral head osteonecrosis that developed during the peripartum period. She received two large intramuscular injections of steroids for fetal lung maturity because early delivery was required as a result of eclampsia. She underwent total arthroplasty of the left hip due to unremitting pain and functional disability, which achieved good clinical results--relieving her pain and improving her range of motion. Literature is scarce with regard to single or dual dose steroid-induced osteonecrosis of the hip as well as pregnancy as a general etiologic factor. This case highlights the need for high clinical suspicion of osteonecrosis as a cause of postpartum hip pain.

Static and dynamic biomechanical adaptations of the lower limbs and gait pattern changes during pregnancy

The purpose of this literature review is to evaluate the studies that have investigated static and dynamic biomechanical changes of the lower limbs and gait patterns during pregnancy. Original articles on this subject, published between 1934 and 2012, were considered. In general, pregnant women demonstrated greater hip flexion, more extended knees and less plantar flexion ankles. These changes could explain the gait patterns of pregnant women characterized by increased hip angles, decreased propulsion forces associated with increased durations of stance phase and changes in distributions of the plantar loads with increased loads in the forefoot and decreased ones in the rearfoot. This can lead to arthrokinematic deviations that, with time, contribute to the development of musculoskeletal discomfort. In summary, these findings showed the importance of further longitudinal studies to investigate the relationships between musculoskeletal discomfort in pregnant women in the lower limbs and gait changes observed throughout this period.

Bilateral osteonecrosis of the femoral head associated with pregnancy: four new cases and a review of the literature

Osteonecrosis is thought to result from the temporary or permanent loss of blood supply to the bones. Without proper nutrition, the bone tissue dies, is resorbed, and collapses. If the process involves the bones in a joint, it often leads to collapse of the joint surface. Four new cases of bilateral osteonecrosis of the femoral head occurring during pregnancy are described, with pathologic examination of core tissue biopsy substantiating the diagnoses. Operative and nonoperative management included anti-inflammatory medication, pulsating electromagnetic fields, core decompression, and total hip replacement. A review of the literature is undertaken to document the reported cases of osteonecrosis of the femoral head associated with pregnancy. Idiopathic osteoporosis of the femoral head is a condition that mimics osteonecrosis of the femoral head and can be a challenge in diagnosis during the latter stages of pregnancy. Bilateral osteonecrosis of the femoral head during pregnancy is rare. Patients may have other predisposing factors leading to femoral head necrosis. Transient osteoporosis of the femoral head during pregnancy can present with a clinical picture similar to osteonecrosis. Avascular necrosis of the femoral head should be considered in the differential diagnosis of pain about the hip developing during pregnancy or in the immediate postpartum period.

Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum

Gender-specific care of musculoskeletal impairments is increasingly important in women's health. This is most relevant and of paramount importance as it relates to identification and management of musculoskeletal and peripheral neurologic disorders of pregnancy, delivery, and postpartum. The specific anatomic and physiologic changes of pregnancy predispose to a specific set of diagnoses. Virtually all women experience some degree of musculoskeletal discomfort during pregnancy. This article provides an overview of the more common pregnancy-related musculoskeletal conditions and includes a discussion of epidemiology, risk factors, diagnosis, prognosis, and management.

Bilateral osteonecrosis of the femoral head after pregnancy

Published cases of non-traumatic avascular necrosis of the femoral head associated with pregnancy are rare. We report a case of a 41-year-old woman who suddenly complained of bilateral hip pain 3 weeks after delivery by Caesarean section. For a problem of sterility, she had been treated with human menopausal gonadotropin and human chorionic gonadotropin (hMG-hCG). Initial radiographs of both hip joints were considered regular. After 4 years' evolution, radiographs of the hip joint showed collapse of both femoral heads. Bilaterally, osteonecrosis of the femoral heads was confirmed by MRI. MRI revealed a band pattern of low signal intensity for both hips on T1- and T2-weighted images. She had no history of steroid therapy or alcohol abuse. Osteonecrosis was related to pretentaine. A bilateral total hip arthroplasty was performed. The literature about avascular necrosis of the femoral head associated with pregnancy in previous cases is reviewed.

Musculoskeletal aspects of pregnancy

Sex-specific care of musculoskeletal impairments is an increasingly important topic in women's health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.

Osteonecrosis of the femoral head associated with pregnancy. A preliminary report

BACKGROUND

Osteonecrosis is usually associated with trauma, use of corticosteroids, or alcohol abuse. We investigated the rare association of osteonecrosis of the femoral head and pregnancy, and we defined differences between the disorder in pregnant women and that in women of childbearing age who were not pregnant. The results of treatment with a free vascularized fibular graft were evaluated in terms of relief of pain and improvement of the Harris hip score after a minimum of two years of follow-up.

METHODS

Thirteen women (seventeen hips) had the onset of pain in the hip during pregnancy or within the first four weeks after delivery, and the pain persisted until a diagnosis of osteonecrosis of the femoral head was made on the basis of magnetic resonance imaging. No patient had any other risk factor for this disease. Information was obtained by means of clinical assessment, a review of the records and radiographs, and a telephone survey. Eleven women (fifteen hips) were managed with a free vascularized fibular graft, and nine of them (eleven hips) were evaluated, with regard to relief of pain and the Harris hip score, at a minimum of two years postoperatively.

RESULTS

The average age when the pain began was 31.5 years (range, twenty-five to forty-one years). Eleven of the thirteen women were primigravid, and the patients typically first had the pain late in the second trimester or in the third trimester of pregnancy. The women tended to have a small body frame and a relatively large weight gain during the pregnancy. Eight of the thirteen patients had swelling and varicosity of the lower extremities. The diagnosis was delayed an average of 10.3 months, with a range of three to thirty months. A common misdiagnosis was transient osteoporosis of the hip during pregnancy. A correct diagnosis was established for all hips on the basis of the finding of a double-density signal on magnetic resonance imaging or evidence of progression of the disease on plain radiographs. According the system of Marcus et al., the stage at the time of diagnosis ranged from II to V. All women had involvement of the left hip, and four had bilateral involvement. Of the eleven women (fifteen hips) who were managed with a free vascularized fibular graft, nine noted marked or complete relief of the preoperative pain. Two hips in a patient who had progressive pain were treated with a total hip arthroplasty. Two hips (one patient) were lost to follow-up. The nine patients (eleven hips) who were available for follow-up at a minimum of two years had an average improvement in the Harris hip score of 24 points.

CONCLUSIONS

Occasionally, pain in the hip that begins during pregnancy is caused by osteonecrosis of the femoral head. A high index of suspicion and use of magnetic resonance imaging may lead to an earlier diagnosis and a better prognosis in this population of women. In this study, treatment with a free vascularized fibular graft was a useful option with which to obviate or postpone the need for total hip arthroplasty.