Osteonecrosis secondary to antiphospholipid syndrome: a case report, review of the literature, and treatment strategy

Treatment options for secondary osteonecrosis of the knee

Knee osteonecrosis is a debilitating progressive degenerative disease characterized by subchondral bone ischemia. It can lead to localized necrosis, tissue death, and progressive joint destruction. For this reason, it is essential to diagnose and treat this disease early to avoid subchondral collapse, chondral damage, and end-stage osteoarthritis, where the only solution is total knee arthroplasty. Three types of knee osteonecrosis have been documented in the literature: spontaneous or primitive, secondary, and post arthroscopy. Spontaneous osteonecrosis is the most common type studied in the literature. Secondary osteonecrosis of the knee is a rare disease and, unlike the spontaneous one, involves patients younger than 50 years. It presents a particular set of pathological, clinical, imaging, and progression features. The management of secondary osteonecrosis is determined by the stage of the disorder, the clinical manifestation, the size and location of the lesions, whether the involvement is unilateral or bilateral, the patient's age, level of activity, general health, and life expectancy. This review aims to present the recent evidence on treatment options for secondary osteonecrosis of the knee, including conservative treatment, joint preserving surgery, and knee replacement.

Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications

Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.

Autologous Osteochondral Transplantation for Young Patients with Postcollapse Osteonecrosis of the Knee: A Retrospective Cohort Study with an Average 7-Year Follow-Up

BACKGROUND

Only a few studies exist that have assessed the efficacy of autologous osteochondral transplantation (AOT) treatment of osteonecrosis (ON) of the knee. The purpose of this study was to clarify the clinical and radiographic results of AOT performed on young patients with postcollapse ON of the knee.

METHODS

This retrospective study included 14 young patients (6 men, 8 women, mean age 34.71 ± 5.41 years) with stage III knee ON undergoing AOT surgery. Mean follow-up time was 87 ± 10.23 months. The postoperative clinical and radiological evaluations were based on Hospital for Special Surgery (HSS) scores and plain x-rays. Paired t tests were used for the statistical analysis by SPSS software.

RESULTS

Preoperative HSS (mean 66.86 ± 7.49 points) was significantly improved at mean 7 years to a postoperative HSS (mean 87.36 ± 8.63 points) (P < 0.001). The postoperative rangeof motion (ROM; 125.71° ± 4.74°) was not significantly different from the preoperative ROM (126.86° ± 7.13°) (P = 0.626). There was no progression of collapse observed in any knees at the last follow-up. No knees required any reoperations during the follow-up period.

CONCLUSION

Fourteen young patients with local ON of the knee were treated by AOT. No progression of bone collapse was seen and clinical improvement sustained at mean 7 years postsurgery. AOT seems to be a safe technique that can give long-term improvement and durability in young ON patients. However, large-sample and high-quality clinical trials are still needed in the future.

Risk of osteonecrosis in systemic lupus erythematosus: An 11-year Chinese single-center cohort study

OBJECTIVE

Osteonecrosis (ON), which can lead to physical disability, is a common complication of systemic lupus erythematosus (SLE). The purpose of this study was to determine the prevalence of ON and identify possible risk factors in Chinese SLE patients.

METHODS

SLE patients who fulfilled the 1997 American College of Rheumatology SLE classification criteria were recruited from the Peking Union Medical College Hospital. The chi-square test (χ² test) and multivariate regression analyses were used to evaluate risk factors. The Cox proportional-hazards model was used to construct the survival curves and estimate the simultaneous effects of prognostic factors on survival.

RESULTS

We consecutively enrolled 1,158 patients, of which 88 patients (7.6%) developed ON. Among ON patients, 57.1% of patients had isolated femoral head necrosis and 42.9% had multiple joint involvement. The mean age of ON patients (24.62 ± 8.89 years) was significantly younger than SLE patients without ON (27.23 ± 10.16 years, p = 0.09). The ON group presented with a much longer disease course (10.68 ± 5.97 years, p < 0.001) and increased incidence of arthritis, kidney, and central nervous system (CNS) involvement (65.9% [p < 0.05], 57.6% [p < 0.05], and 16.5% [p < 0.05], respectively, in the ON group). ON patients were more likely to be treated with glucocorticoid (GC) and to receive a high dose of prednisolone at the initial stage of SLE (p < 0.05). The percentage of patients who received hydroxychloroquine was much higher in the control group (p < 0.001). Cox regression analysis suggested that CNS involvement and GC therapy were two independent risk factors for ON in SLE patients. The presence of anti-phospholipid antibodies (aPLs) was a risk factor for multiple joint necrosis (odds ratio: 6.28, p = 0.009).

CONCLUSIONS

ON remains a serious and irreversible complication in SLE. In addition to glucocorticoid therapy, we found that CNS system involvement was a risk factor for ON, while the administration of hydroxychloroquine was a protective factor. The clinical characteristics of multiple site ON patients were distinct from isolated femoral head necrosis patients. The presence of aPLs was a risk factor for multiple site osteonecrosis.

[Atypical arthritis of the hands : Collagenosis-part 1]

BACKGROUND

Systemic lupus erythematosus (SLE) is a gynecotropic autoimmune vasculitis with manifestations in various organ systems including the skin, internal organs, and joints.

OBJECTIVE

Presentation of the atypical arthritis patterns of the hands in SLE as the most common autoimmunologic rheumatologic disease from the group of collagenoses in the context of clinical and serological findings and considering the classification criteria of the American College of Rheumatology compared to rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

MATERIALS AND METHODS

Narrative review based on the current literature on the subject from a radiological and rheumatological point of view.

RESULTS

In 80-90% of all SLE cases, hand joint manifestations can be detected, mostly in the form of non-erosive oligo- or polyarthralgias with the picture of so-called luxation arthropathies and with the pattern of a so-called Jaccoud's or Lupus' syndrome, which are accompanied by "carpal instability" in 15% of cases. In association with an antiphospholipid antibody syndrome, ischemic osteonecrosis may occur in 5-50% of SLE, predominantly in weight-bearing areas of the skeleton, and less frequently in the carpal bones or metacarpal heads. The rare rhupus syndrome comprises patients with overlap of RA and SLE features.

CONCLUSIONS

Due to the heterogeneity of the symptoms and the often individually very different courses, the diagnosis of SLE can be difficult. Since new drug therapy concepts have significantly increased the 5‑year survival rates of SLE from 0% in the 1950s to 70-90% in recent decades, a timely and definite diagnosis is necessary, to which radiologists can also contribute by correctly classifying the image morphological SLE arthritis patterns in the hands.

The treatment of anti-phospholipid syndrome: A comprehensive clinical approach

Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.

Fresh Osteochondral Allograft Transplantation for Spontaneous Osteonecrosis of the Knee: A Case Series

Background:

Spontaneous osteonecrosis of the knee (SONK) is a clinical entity identified by acute knee pain usually associated with joint effusion, with radiographic findings of a radiolucent defect on the weightbearing area of the femoral condyle. Conservative treatment is initially undertaken; however, surgical procedures are often necessary. Historically, surgical options have included core decompression, cartilage repair, high tibial osteotomy, or joint arthroplasty. Few studies in the literature have reported the use of fresh osteochondral allograft (OCA) for the treatment of SONK lesions.

Hypothesis:

OCA transplantation is an effective treatment for SONK lesions on the medial femoral condyle.

Study Design:

Case series; Level of evidence, 4.

Methods:

A case series was analyzed of 7 patients treated with OCA for large SONK lesions of the medial femoral condyle with a minimum 4-year follow-up. All patients experienced failure of at least 6 months of conservative treatment and declined arthroplasty as the form of definitive treatment for medial femoral condyle lesion. All patients underwent OCA of the medial femoral condyle. Mean lesion size was 4.6 cm² (range, 3.24-6.25 cm²), with a mean condylar width of 41.7 mm (range, 35.4-48.6 mm), resulting in a median proportion (lesion size/condylar width) of 56.8% (range, 32.7%-62.6%). The median surface allograft area was 5.1 cm² (range, 3.2-6.3 cm²).

Results:

The median follow-up was 7.1 years (range, 4.5-14.1 years). No patient had additional surgery following OCA transplant; the allograft failure rate was 0%. Subjective outcome scores from the International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, and modified Merle d’Aubigné-Postel scale improved from preoperative assessment to the latest follow-up. All patients were extremely satisfied with the results of the OCA transplant.

Conclusion:

Fresh OCA transplantation demonstrated excellent efficacy, durability, and satisfaction in this group of patients with isolated stage 2 and 3 SONK lesions who had experienced failure of conservative treatment. Fresh osteochondral allografts are an attractive method for surgical management of selected patients with spontaneous osteonecrosis of the knee.

Musculoskeletal manifestations of the antiphospholipid syndrome

The scope of clinical and laboratory manifestations of the antiphospholipid syndrome (APS) has increased dramatically since its discovery in 1983, where any organ system can be involved. Musculoskeletal complications are consistently reported in APS patients, not only causing morbidity and mortality, but also affecting their quality of life. We reviewed all English papers on APS involvement in the musculoskeletal system using Google Scholar and Pubmed; all reports are summarized in a table in this review. The spectrum of manifestations includes arthralgia/arthritis, avascular necrosis of bone, bone marrow necrosis, complex regional pain syndrome type-1, muscle infarction, non-traumatic fractures, and osteoporosis. Some of these manifestations were reported in good quality studies, some of which showed an association between aPL-positivity and the occurrence of these manifestations, while others were merely described in case reports.

Rituximab usage in systemic lupus erythematosus-associated antiphospholipid syndrome: A single-center experience

OBJECTIVES

Although the data from primary antiphospholipid syndrome (APS) suggests a beneficial effect of rituximab usage, its therapeutic role remains to be defined in systemic lupus erythematosus (SLE)-associated APS, a complex clinical situation with thrombotic events and lupus activity.

METHODS

A single-center retrospective analysis of rituximab usages in APS was performed in 800 hospitalized SLE patients.

RESULTS

There were 63 SLE-associated APS cases with 6 on rituximab therapy, all female aged 37.7 ± 9.0 years with 1 catastrophic and 16 thrombotic episodes. Therapeutic indications included warfarin failure despite the adequate target international normalized ratio with an average duration of 17.3 ± 11.2 months between the thrombotic recurrences. After the rituximab therapy, there was no relapse of thrombosis with a mean follow-up period of 39.3 ± 20.9 months, and a decrease in lupus activity (SLEDAI-2K, 9.7 ± 5.5 to 5.3 ± 2.2). Infection complications were observed, including episodes of bronchitis and urinary tract infection.

CONCLUSIONS

In this single-center study with largest case numbers and a long-term follow-up period, there were no recurrent thrombotic events after the rituximab therapy, implicating further consideration of large-scale trials enrolling more ethnic groups to evaluate its therapeutic role in SLE-associated APS patients.

Top 10 clinical research developments in antiphospholipid syndrome

Persistently positive antiphospholipid antibodies (aPL) with thrombosis and/or pregnancy morbidity are a characteristic of antiphospholipid syndrome (APS). Although many challenges and controversies exist regarding APS diagnosis and management, there has been significant progress in APS clinical research in parallel with increased understanding of the pathogenesis. The purpose of this review is to discuss the "top ten" recent clinical developments in APS, including the magnitude of the problem, standardization of aPL tests, predictors of clinical events, diagnostic algorithms, new clinical research collaboration, and potential future treatments, e.g., new anticoagulants and immunosuppressive agents.

8th International Congress on Autoimmunity: new perspectives for refractory catastrophic antiphospholipid syndrome

The 8th edition of the International Congress on Autoimmunity took place in the beautiful and historical city of Granada, Spain, from 9 to 13 March 2012. It gathered more than 2350 participants from 71 different countries, including internists, immunologists, rheumatologists, basic researchers and many other clinicians and laboratory people interested in autoimmune diseases who were updated with the latest available diagnostic tools and new therapeutic avenues. This top international autoimmunity meeting put together an international faculty of more than 100 experts to present a high-level scientific program under the leadership of Professor Yehuda Shoenfeld (Zabludowicz Center for Autoimmune Diseases, Tel-Hashomer, Israel) who chaired the congress together with Ricard Cervera (Hospital Clínic, Barcelona, Catalonia, Spain), Angela Tincani (University of Brescia, Italy) and Carlos Vasconcelos (Hospital S. António, Porto, Portugal) as co-chairpersons.

The use of monoclonal antibodies in immune-mediated hematologic disorders

In this article, the evidence on the clinical use of monoclonal antibodies in the treatment of immune-mediated hematologic disorders is described. Insights into pathogenic mechanisms have revealed a major role of both B and T cells. Controlled trials have shown conflicting results, necessitating further research regarding pathogenesis, mechanism of action, and resistance. Although the use of more potent and specific monoclonal antibody therapy, mainly targeting costimulation signals, may improve response rates and long-term outcome, its use should be carefully balanced against potential side effects.

Management of refractory cases of catastrophic antiphospholipid syndrome

The catastrophic variant of the antiphospholipid syndrome (APS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Refractory catastrophic APS may be defined as patients who did not respond to first-line therapies (anticoagulation, glucocorticoids and plasma exchange and/or intravenous immunoglobulins) and died in the acute phase of the episode or patients with recurrent episodes of catastrophic APS. The purpose of this review is to focus on the current management of these refractory patients and some of the potential new therapeutic approaches.