[Pain management in non-juvenile, aseptic osteonecrosis]

[Drug treatment of osteonecrosis]

The medicinal treatment of osteonecrosis is described as part of the conservative treatment for atraumatic femoral head necrosis of the hip in adults and for Ahlbäck's disease of the knee joint. For femoral head necrosis, iloprost is used in the early stages (ARCO I and II) as a treatment attempt to eliminate pain and the accompanying bone marrow edema. This also applies to the use of bisphosphonates, whereby preferably small defects (< 30%) are suitable for treatment. Bisphosphonates are successfully used in the knee joint to treat Ahlbäck's disease, although the results are sometimes contradictory. Other locations, such as the humeral head, talus, scaphoid, lunate, proximal tibia, and metatarsal head, are sometimes successfully treated with bisphosphonates. Although the results seem promising, the groups are far too small to derive treatment recommendations in this regard.

[Conservative treatment of atraumatic femoral head necrosis]

BACKGROUND

Femoral head necrosis is a progressive disease that can progress within a relatively short time. Therefore, an early and clear diagnosis including stage classification and treatment is necessary to prevent or delay the onset of the femoral head and joint destruction.

TREATMENT

In addition to the identification of possible risk factors and treatment, the question of the available treatment options arises. The present article deals with conservative treatment options and presents the published results in the sense of the currently available evidence and against the background of the S3 guideline on atraumatic femoral head necrosis. The results of physical therapy, drug therapy (iloprost and bisphosphonates ), electrotherapy, shockwave therapy, etc. are presented. In the early stages of femoral head necrosis with low expansion, alendronate gives positive results. Iloprost is also a successful conservative treatment option in the early stages of atraumatic femoral head necrosis (ARCO I and II). In stages ARCO III and IV, Ilomedin is no longer indicated. Anticoagulants, such as enoxaparin, have demonstrated an arthroprotective effect.

Atraumatic Femoral Head Necrosis in Adults

BACKGROUND

Atraumatic necrosis of the femoral head is a common cause of hip arthrosis in middle age. In Germany, it affects 5000-7000 patients per year, corresponding to an incidence of 0.01%. Though rarer than primary hip arthrosis, it is still of major clinical and socio-economic significance. Patients with this problem should be diagnosed early and given stage-appropriate treatment.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed, Embase, Medline, and Cochrane Library databases using the terms "osteonecrosis," "femoral head necrosis," "diagnosis," "classification," "conservative treatment," "surgical treatment," "joint preservation," "osteotomy," and "arthroplasty," as well as a recent guideline on atraumatic necrosis of the femoral head in adults.

RESULTS

The etiology and pathogenesis of atraumatic femoral head necrosis in adults are not yet fully clear. The main risk factor is prolonged corticosteroid treatment. Nonspecific complaints and an initially normal plain x-ray of the hip can delay the diagnosis. The diagnosis is established by plain x-ray, computerized tomography, magnetic resonance tomography, and scintigraphy. Conservative treatment alone is not considered adequate. The range of surgical treatments includes joint-preserving and (for more severe necrosis) joint-resecting methods.

CONCLUSION

Atraumatic femoral head necrosis in adults is a disease that progresses in stages; depending on its stage, it can either be cured or lead to hip arthrosis. A full cure is possible only in early stages. Current research focuses on the effect of new drugs on the intermediateand long-term outcome.

S3-Guideline non-traumatic adult femoral head necrosis

INTRODUCTION

The treatment of adult non-traumatic avascular necrosis of the femoral head (AVN; N-ANFH) within an estimated incidence of 5000-7000 cases per annum in Germany remains a challenge. Risk factors include steroids, alcohol abuse, chemotherapy and immunosuppressive medication, but a genetic predisposition has been suggested. Early diagnosis of this often bilateral disease process is essential for successful conservative or joint preserving surgical management. In this review, we present the update German consensus S3 guideline "diagnosis and management for N-ANFH" as a concise summary.

MATERIALS AND METHODS

This systematic review is based on the published literature from January 1, 1970 to April 31, 2013 (German and English language). Inclusion criteria were systematic reviews, meta-analyses and relevant peer review publications. We identified a total of 3715 related publications, of which 422 were suitable according to the SIGN criteria, but only 159 fulfilled our inclusion criteria.

RESULTS AND CONCLUSIONS

Clinical suspicion of N-ANFH mandates radiographic evaluation. If radiographs are normal MRI scans are recommended, which should be evaluated according to the ARCO-classification. Differential diagnoses include transient osteoporosis, bone bruise, insufficiency fracture and destructive arthropathy. Untreated, subchondral fractures commonly occur within 2 years, during which the risk for contralateral involvement is high-thereafter unlikely. Conservative management with Ilomedin and Alendronat can be tried, but other pharmacological or physical treatments are inappropriate. No specific joint preserving procedure can be recommended, but core decompression should be considered in early stages if necrosis is <30 %. In ARCO stages IIIc or IV total hip arthroplasty (THA) should be contemplated, which offers similar outcome compared to osteoarthritis. Young age is the main risk factor for higher revision rates after THA for N-ANFH.

Efficiency of iloprost treatment for osseous malperfusion

Insufficient osseous blood supply results in bone marrow oedema (BMO) and/or avascular necrosis (AVN). One treatment option to support osseous perfusion is the application of stable prostacycline analog iloprost. In this clinical study, 95 patients were treated with iloprost for BMO/AVN. One hundred eighty-six bones were affected by BMO/AVN before treatment. Average follow-up was 33.0 ± 17.6 months. Pain levels could be reduced (e.g. visual analogue scale, 5.0 ± 2.2 points reduced to 1.7 ± 2.2 points) and functional scores improved (Harris hip score, 52 ± 21 points to 79 ± 17 points) in the course of treatment. According to current data, healing of advanced stages of osteonecrosis is not possible. However, the results of this case series confirm previous findings that in early stages of insufficient osseous blood flow iloprost can contribute to the relief of pain and improve joint function.

Rationale for prostaglandin I2 in bone marrow oedema--from theory to application

Introduction

Bone marrow oedema (BME) and avascular osteonecrosis (AVN) are disorders of unclear origin. Although there are numerous operative and non-operative treatments for AVN, pain management in patients with AVN remains challenging. Prostaglandins play an important role in inflammatory responses and cell differentiation. It is thought that prostaglandin I₂ ([PGI₂] or synonoma prostacyclin) and its analogues promote bone regeneration on a cellular or systemic level. The purpose of this study was to assess the curative and symptomatic efficacy of the prostacyclin analogue iloprost in BME and AVN patients.

Method

We are reporting on 50 patients (117 bones) affected by BME/AVN who were treated with iloprost. Pain levels before, during and 3 and 6 months after iloprost application were evaluated by a visual analogue scale (VAS). The short form(SF)-36 health survey served to judge general health status before and after treatment. Harris Hip Score (HHS) and Knee Society Score (KSS) were performed as functional scores and MRI and X-rays before and 3 and 6 months after iloprost application served as objective parameters for morphological changes of the affected bones.

Results

We found a significant improvement in pain, functional and radiological outcome in BME and early AVN stages after iloprost application, whereas patients with advanced AVN stages did not benefit from iloprost infusions. Mean pain level decreased from 5.26 (day 0) to 1.63 (6 months) and both HHS and KSS increased during follow-up. Moreover, the SF-36 increased from 353.2 (day 0) to 560.5 points (6 months). We found a significant decrease in BME on MRI scans after iloprost application.

Conclusions

In addition to other drugs, iloprost may be an alternative substance which should be considered in the treatment of BME/AVN-associated pain.

Surgical treatment of AVN of the fibular (lateral) sesamoid

Despite the fact that the hallucal sesamoids play a crucial role in forefoot mechanics, disorders resulting from pathology of these structures are often overlooked or misdiagnosed. Avascular necrosis (AVN) of the hallucal sesamoids is a rare condition that must be differentiated from other pathologies, such as fractures, pseudarthrosis or osteomyelitis. We report on two patients with AVN of the fibular (lateral) hallucal sesamoid (Morbus Renander). In both patients the necrotic part of the fibular sesamoid was excised surgically after failed conservative therapy. The followup was 29 and 26 months. The clinical and radiological results showed a complete relief of pain in both patients without any complications or forefoot deformities. Recent literature and own experiences support non-operative initial management including anti-inflammatory medications, shoe modification and temporary limited weight bearing. If symptoms persist, surgical treatment with excision of the necrotic part of the sesamoid may be an alternative. Consideration by the surgeon should be given to protecting the neurovascular bundle and reattaching intrinsic tendons and ligaments if necessary. Satisfying results can be achieved by surgical removal.

Avascular osteonecrosis after hyperthermia in children and adolescents with pelvic malignancies: a retrospective analysis of potential risk factors

PURPOSE

In children with locally advanced or recurrent malignant tumours, prognosis can be improved by regional deep hyperthermia (RHT) in combination with platin-based chemotherapy. However, because of the increasing number of patients that achieve long-time remission with this therapy, it is necessary to evaluate long-term sequelae of thermochemotherapy. During the years 1993-2004 one has observed avascular osteonecrosis (AON) of the femoral head after RHT in seven children with pelvic germ cell tumours or rhabdomyosarcomas.

METHODS

Although AON may develop in patients with malignancies treated with chemo- or radiotherapy alone, RHT might nevertheless contribute to the occurrence of AON. In order to determine potential risk factors for AON after RHT, this study analysed the relationship of AON to the patient's age, medical history and treatment parameters such as thermal dose equivalent and power output.

RESULTS AND CONCLUSIONS

In the present study AON was associated with young age as well as intensity of hyperthermia indicated by high power levels that exceed 20 W per kg body weight and/or application of eight or more heat sessions as well as additional radiotherapy. Based on this observation, it was assumed that an optimized three dimensional thermal field modelling may be helpful to avoid hazardous temperatures in the femoral heads during RHT treatment and to reduce AON of the femoral heads.