Risk factors for nontraumatic osteonecrosis of the femoral head after renal transplantation

Prevalence of Musculoskeletal Manifestations in Adult Kidney Transplant's Recipients: A Systematic Review

Background and Objectives: The musculoskeletal (MSK) manifestations in the kidney transplant recipient (KTxR) could lead to decreased quality of life and increased morbidity and mortality. However, the prevalence of these MSK manifestations is still not well-recognized. This review aimed to investigate the prevalence and outcomes of MSK manifestations in KTxR in the last two decades. Materials and Methods: Research was performed in EBSCO, EMBASE, CINAHL, PubMed/MEDLINE, Cochrane, Google Scholar, PsycINFO, Scopus, Science Direct, and Web of Science electronic databases were searched during the years 2000–2020. Results: The PRISMA flow diagram revealed the search procedure and that 502 articles were retrieved from the initial search and a total of 26 articles were included for the final report in this review. Twelve studies reported bone loss, seven studies reported a bone pain syndrome (BPS) or cyclosporine-induced pain syndrome (CIPS), and seven studies reported hyperuricemia (HU) and gout. The prevalence of MSK manifestations in this review reported as follow: BPS/CIPS ranged from 0.82% to 20.7%, while bone loss ranged from 14% to 88%, and the prevalence of gout reported in three studies as 7.6%, 8.0%, and 22.37%, while HU ranged from 38% to 44.2%. Conclusions: The post-transplantation period is associated with profound MSK abnormalities of mineral metabolism and bone loss mainly caused by corticosteroid therapy, which confer an increased fracture risk. Cyclosporine (CyA) and tacrolimus were responsible for CIPS, while HU or gout was attributable to CyA. Late diagnosis or treatment of post-transplant bone disease is associated with lower quality of life among recipients

Incidence and risk factors for osteonecrosis of the hip in renal transplant patients: a prospective single-centre study

BACKGROUND

There is a lack of evidence about the risk factors associated with osteonecrosis of the femoral head (ONFH).

PURPOSES

To determine the incidence and risk factors for ONFH following renal transplantation (RT).

METHODS

In total, data of 681 RT patients (mean age at surgery, 49.5 ± 13.6 years; 249 women and 432 men) were evaluated to determine the incidence of ONFH. Hip magnetic resonance imaging (MRI) was performed six months after RT. The following potential predictors of ONFH were evaluated: (1) patient's condition at RT; laboratory test results including calcium (Ca), phosphorus (P), calcium-phosphorus product (Ca × P), and intact parathyroid hormone before RT; blood relationship between the patient and donor; and mismatching number of human leukocyte antigens (HLAs), especially HLA class I and class II and (2) dosages of steroids after RT, immunosuppressive regimen, and incidence of acute rejection.

RESULTS

ONFH was observed in 30 hips (21 cases, 3.1%). We successfully matched 63 patients without ONFH. Multivariate logistic regression analysis, adjusted for cumulative dosages of steroids, revealed that mismatching number of HLA (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.10-2.36; p = 0.014), HLA class II (HR, 3.73; 95% CI, 1.46-9.56; p = 0.001), P before RT (HR, 1.62; 95% CI, 1.02-2.58; p = 0.041), and Ca × P  before RT (HR, 1.06; 95% CI, 1.01-1.11; p = 0.024) were risk factors for ONFH.

CONCLUSION

A greater number of HLA mismatches, HLA class II, serum P, and serum Ca × P were risk factors for ONFH after RT. Therefore, these factors should be evaluated in order to predict ONFH after RT.

Screening of Serum Protein Markers for Avascular Osteonecrosis of Femoral Head Differentially Expressed after Treatment with Yuanshi Shengmai Chenggu Tablets

Avascular necrosis of the femoral head (ANFH) is an a frequently occurring orthopaedic disease with high morbidity. Traditional Chinese Medicine (TCM) Yuanshi Shengmai Chenggu Tablet is a valid prescription for treating steroid-induced femoral head necrosis. However, there are rare investigations about the serum protein marker expression after the acting of drugs on hormone and TCM. In the present study, we aimed to systematically discover and validate the serum biomarkers expression difference in patients with steroid-induced avascular necrosis of femoral head (SANFH) after taking Yuanshi Shengmai Chenggu Tablets (SANFH-TCM), so as to reveal the action mechanism of TCM from the molecular level by using isobaric tags for relative and absolute quantification (iTRAQ) with multiple reaction monitoring quantification. Significant differences in fibrinogen alpha, fibrinogen beta, fibrinogen gamma, fibronectin, C-reactive protein, apolipoprotein A, apolipoprotein D, and apolipoprotein E were found among SANFH, SANFH-TCM, and healthy controls. Therefore, our study proposes potential biomarkers for SANFH diagnosis and for the prognosis of femoral head necrosis after Traditional Chinese Medicine treatment.

Association of common comorbidities with osteonecrosis: a nationwide population-based case-control study in Denmark

OBJECTIVE

To examine recent time trends in the incidence of osteonecrosis (ON) in Denmark and to investigate different common comorbidities association with ON in a population-based setting.

METHODS

Using Danish medical databases, we included all patients with a first-time hospital diagnosis of ON during 1995-2012. Each ON case was matched with 10 randomly selected population control subjects from general population. For all participants, we obtained a complete hospital history of comorbidities included in the CharlsonComorbidity Index 5 years preceding the inclusion date.

RESULTS

4107 ON cases and 41 063 controls were included. The incidence of ON increased from 3.9 in 1995 to 5.5 in 2012 per 100 000 inhabitants. Solid cancer was the most common comorbidity, associated with an adjusted OR (aOR) for ON of 2.0 (95% CI 1.7 to 2.2). For advanced metastatic cancer, leukaemia and lymphoma, aORs of ON were 3.4 (95% CI 2.5 to 4.5), 4.3 (95% CI 2.7 to 7.0) and 5.8 (95% CI 4.3 to 7.8), respectively. Among other chronic conditions, aORs were 3.5 (95% CI 3.0 to 4.1) for connective tissue diseases and 2.3 (95% CI 2.0 to 2.7) for chronic pulmonary diseases. aORs were also increased at 2.8 (95% CI 1.9 to 4.1) and 4.5 (95% CI 2.5 to 8.2) for mild and moderate-to-severe liver disease, respectively, and 4.2 (95% CI 3.4 to 5.2) for renal disease.

CONCLUSION

This large population-based study provides evidence for an increasing ON incidence in the general population and documents an association between several common comorbid conditions and risk of ON.

Increased serum protein levels by Yuanshi Shengmai Chenggu Tablet in treatment of avascular osteonecrosis of the femoral head

The traditional Chinese medicine (TCM) Yuanshi Shengmai Chenggu Tablet is used for treating the common orthopedic disease, hormone‑induced avascular necrosis of the femoral head (ANFH) in China. However, its underlying mechanism and the changes induced in the treatment of ANFH remain to be fully elucidated. In the present study, through the use of isobaric Tag for Relative and Absolute Quantitation and multiple reaction monitoring quantifications, corticosteroid‑induced femoral head necrosis and the effects of treatment with Yuanshi Shengmai Chenggu Tablet were examined. The aim was to identify serum proteins, which may be potential serum markers for the early clinical diagnosis of ANFH, and maybe used to develop more rapid and convenient detection strategies. A total of five proteins were identified, comprising Ig mu chain C region, keratin, type I cytoskeletal 9, properdin, apolipoprotein A‑IV, and IQ and AAA domain‑containing protein 1. The expression levels of all five proteins were lower in ANFH and were higher following TCM treatment. These findings were confirmed using ELISA and western blot analysis.

Long-term Clinical Results after Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis

The treatments of avascular osteonecrosis (AVN) include both conservative and surgical methods which are dependent on the stage and progression of the disease. The vasoactive-prostaglandin-analogue iloprost (PGI2) has been utilized in several areas of medicine and recently has been used for the treatment of AVN. A total of 108 patients with 136 osteonecrosis of different joints, etiology and severity were treated with iloprost. The mean follow-up was 49.71 months: range 15-96 months, and outcome measurements recorded regarding subjective complaints, visual analog scale (pain), function and survival. The outcome scores used include the Harris Hip Score, Knee Society score, Foot and Ankle Survey, visual analogue scale (VAS) and a separate questionnaire. The location and etiology of AVN in our study demonstrated the typical pattern. All of the observed side effects of the therapy were minor and completely reversible. Most of patients (74.8%) showed a significant improvement of subjective complaints and decrease in VAS pain scores after the treatment with iloprost. However, 20% of the treated joints with the stadium Association for Research on Osseous Circulation (ARCO) grade 2, 71% with ARCO 3 and 100% with ARCO 4 underwent subsequent total joint replacement. The medical treatment of bone marrow edema or avascular osteonecrosis by Iloprost provides an safe and effective alternative strategy in the management of AVN presenting in the early stages (ARCO 1 or 2). For more advanced stages (ARCO 3 or 4), surgical intervention should be prioritized.

Long-Term Outcome after Rehabilitation of Bilateral Total Hip Arthroplasty in Renal Transplant Recipient - A Case Report

INTRODUCTION:

Total hip replacement is generally proposed for renal transplant patients with avascular osteonecrosis of the femoral head.

PURPOSE:

The purpose of the study is to report the long-term outcome after rehabilitation of bilateral total hip arthroplasty in a patient with renal transplantation suffering from avascular osteonecrosis of the both femoral heads.

MATERIAL AND METHOD:

The patient S.D, 49 years old at follow-up. Few months after renal transplantation, the patient had got avascular osteonecrosis of both femoral head. One year after transplantation the total hip arthroplasty for both hip joints were performed. Three years later repeat total hip arthroplasty surgery for left hip was performed. After any surgery intervention the patient was referred for inpatient rehabilitation. For clinical assessment the clinical findings and Harris Hip Score have been used. The rehabilitation program consisted of exercises, occupational therapy, and patient education.

RESULTS:

After any rehabilitation treatment the patient had improvement of clinical findings. At follow-up assessment outcome for both hip function was good - Harris Hip Score was 81 points.

CONCLUSION:

Rehabilitation is integral part of multidisciplinary treatment of renal transplant recipient after total hip arthroplasty. Regular exercise training of these patients is very important for improving of their long-term outcome.

Two-year follow-up after advanced core decompression

The so-called "Advanced Core Decompression" (ACD) is a new option that tries to remove the necrotic tissue in patients with osteonecrosis of the femoral head (AVN) in a minimally invasive way by the use of a percutaneous expandable reamer and refilling with a resorbable and osteoinductive bone-graft substitute. Seventy-two hips of sixty patients with a mean follow-up of 29.14 months after ACD have been included in this study. Patients underwent physical examination preoperatively and six weeks after surgery as well as at two further follow-ups. Certain phases in disease progression and size of the necrotic lesion were differentiated on the basis of the classification of osteonecrosis of the femoral head by Steinberg.The femoral heads had collapsed in 24 cases (33%). Analysis of the survival rates with regard to defect size revealed that the largest defects had a significantly higher rate of femoral head collapse than the smaller defects. Clinical scores were also depending on defect size but also on disease stage. The current ACD technique has not yet achieved any significant improvement in the success rate of core decompression procedures. It can be concluded that the success of ACD depends especially on the defect size. Copyright © 2015 John Wiley & Sons, Ltd.

Effect of kidney-reinforcing and marrow-beneficial traditional Chinese medicine-intervened serum on the proliferation and osteogenic differentiation of bone marrow stromal cells

The present study aimed to investigate the effect of kidney-reinforcing and marrow-beneficial traditional Chinese medicine (TCM)-intervened (KRMBTI)-serum on the proliferation and osteogenic differentiation of bone marrow stromal cells (BMSCs) in rats. Rat BMSCs were isolated and cultured in vitro with various concentrations of serum obtained from rats at different time-points following treatment with low, medium and high doses of KRMBT. The alkaline phosphatase (ALP) activity and proliferation of the BMCSs was assessed to determine the optimal serum sampling time-point and serum concentration. Transforming growth factor (TGF)-β1 expression of the BMSCs was detected using enzyme-linked immunosorbent assay (ELISA), and hepcidin mRNA expression in the rat livers was detected using reverse transcription polymerase chain reaction. The proliferation of BMCSs treated with serum obtained l h after dosing was observed to be significantly higher than that for BMCSs treated with serum obtained at the four other time-points (P<0.05). Furthermore, the proliferation following treatment with 25% KRMBTI-serum was significantly higher than that for the other KRMBTI-serum concentrations (P<0.01). For a 25% concentration of the serum collected at l h, the proliferation in the high- and low-dose KRMBTI-serum groups was significantly higher than that of the medium-dose and control groups (P<0.01) and no statistical significance was observed between the high- and low-dose groups. In the osteogenic differentiation process of the high-dose group, the ALP activity at every time-point was significantly higher than that of the low-dose group and the peak value of the former was achieved at concentrations between 20 and 30%. KRMBTI-serum was shown to promote the expression of TGF-β1. Furthermore, hepcidin was observed to be expressed at significantly higher levels in the high-dose group than in the control group, and hepcidin expression was significantly higher after 10 weeks compared with that after five weeks. These findings suggest that KRMBTI-serum increases TGF-β1 and hepcidin expression levels, which may be the mechanism underlying the promotion of osteogenic differentiation induced by KRMBTI-serum in BMSCs.

Estimation of minimum whole-blood tacrolimus concentration for therapeutic drug monitoring with plasma prednisolone concentration: A retrospective cohort study in Japanese kidney transplant recipients

BACKGROUND

In immunosuppressive therapy administered after organ transplantation, therapeutic drug monitoring (TDM) of tacrolimus must be performed frequently because of the large variation in its pharmacokinetic properties and a progressive decrease in dose requirements. An indicator for estimating the target minimum whole-blood tacrolimus concentration (Cmin TAC) would be useful to minimize the number of blood samplings required for tacrolimus TDM.

OBJECTIVES

The primary objective of this study was to investigate whether plasma prednisolone concentration, postoperative days (POD) and AUC 0 to 9 hours before transplantation (AUC0-9int) are useful indicators of tacrolimus TDM. The secondary objective was to determine the usefulness of blood tacrolimus concentration as an indicator of the development of nontraumatic, glucocorticoid-induced necrosis of the femoral head, an adverse event that has been associated with the use of prednisolone in vivo.

METHODS

This open-label, nonrandomized, retrospective study was conducted at the Department of Transplantation and Regenerative Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan. Data from 43 male and 22 female patients (mean age, 38 years [range, 9-64 years]) who received a living-related kidney transplant from 2001 to 2004 were included. Multiple blood samplings were performed to determine AUC0-9int, AUC 0 to 9 hours after drug administration and after transplantation (AUC0-9), Cmin TAC, Cmax, and Tmax after transplantation. The correlations between each parameter were determined. The correlation between POD and the changes in tacrolimus bioavailability was investigated using the indicator, defined as the tacrolimus dose required to maintain the target (10-15 ng/mL) Cmin TAC (dose/C10-15). Correlations between dose/C10-15 and AUC0-9int (3 AUC0-9int groups, defined as follows: low, medium, and high [<93, ≧93-≤152, and ≧152 ng·h/mL, respectively]) were determined. Correlations between mean Cmin values of prednisolone at a dose of 40 mg on PODs 4 to 11 (Cmin PSL40) and Cmin TAC, or AUC0-9int were determined. A subanalysis was used to determine the relationship between dose/C10-15 and the prevalence of nontraumatic, glucocorticoid-induced necrosis of the femoral head.

RESULTS

Cmin TAC was found to be significantly correlated with AUC0-9int (r=0.554; P<0.001) and Cmin PSL40 (r=0.336; P<0.001). In the low-AUC0-9int group, dose/C10-15 was higher than that of the other groups (P<0.001). AUC0-9int was significantly correlated with Cmin PSL40 (r=0.445; P<0.001)). Dose/C10-15 in the patient group that had necrosis of the femoral head was lower than that of the group without necrosis (n=6; P<0.01).

CONCLUSIONS

The results of this small, retrospective study suggest that Cmin PSL40, AUC0-9int, and POD were significant predictors of Cmin TAC. These parameters were found to be a useful indicator of tacrolimus TDM in these Japanese transplant recipients. Our results also suggest that dose/C10-15 and AUC0-9int might be useful indicators for estimating the risk for nontraumatic, steroid-induced necrosis of the femoral head. (Curr Ther Res Clin Exp. 2006;67: 103-117) Copyright © 2006 Excerpta Medica, Inc.

Glucocorticoids (as an Etiologic Factor)

Adrenocortical hormones were first prepared from the adrenal gland as a new compound by Kendall in 1935 [1]. Thirteen years later, Hench et al. [2] observed a miraculous effect of cortisone in a patient with severe rheumatoid arthritis, which opened new doors to innovative treatments for a variety of inflammatory diseases. Against this background, Kendall, Hench, and Reichstein were awarded the 1950 Nobel Prize for Physiology or Medicine. Since then, glucocorticoids have been used as a first-line therapy for immune-mediated conditions or as an adjunctive therapy in many inflammatory, infectious, or malignant diseases.

The pathogenesis of nontraumatic osteonecrosis

Nontraumatic osteonecrosis continues to be a challenging problem causing debilitating major joint diseases. The etiology is multifactorial, but steroid- and alcohol-induced osteonecrosis contribute to more than two thirds of all cases with genetic risk factors playing an important role in many other cases, especially when they contribute to hypercoagulable states. While the exact mechanisms remain elusive, many new insights have emerged from research in the last decade that have given us a clearer picture of the pathogenesis of nontraumatic osteonecrosis of the femoral head. Progression to end stage osteonecrosis of the femoral head appears to be related to four main factors: interactions involving the differentiation pathway of osteoprogenitor cells that promote adipogenesis, decreased angiogenesis, direct suppression of osteogenic gene expression and proliferation of bone marrow stem cells, and genetic anomalies or other diseases that promote hypercoagulable states.

Pronounced risk of nontraumatic osteonecrosis of the femoral head among cigarette smokers who have never used oral corticosteroids: a multicenter case-control study in Japan

BACKGROUND

Cigarette smoking has been linked to an increased risk of nontraumatic osteonecrosis of the femoral head (ONFH) in previous studies. However, the effect of smoking amount, duration and cessation, and interaction with corticosteroids remains unclear. The purpose of this study was to precisely evaluate the effects of smoking and the interaction with corticosteroid use.

METHODS

This was a multicenter, matched case-control study in Japan. Cases were defined as patients who were newly diagnosed with ONFH at an initial visit or during the previous year if they were referred patients. For each case, matched controls were selected from patients without ONFH. The matching conditions were sex, age, and ethnicity. A logistic regression model was used to compute odds ratios (OR) and 95 % confidence intervals (95 % CI).

RESULTS

We compared 72 cases with 244 matched controls. ORs were 3.89 (95 % CI 1.46-10.4) for current smokers, 3.89 (1.22-12.4) for smokers consuming more than 20 cigarettes per day, 4.26 (1.32-13.7) for smokers with 26 pack-years or more, and 3.11 (0.92-11.5) for smokers with a history of 29 years or more, with significant or marginally significant dose-response relationships. OR for current smokers was 10.3 among those who had never used corticosteroids and 1.56 among past or current corticosteroid users (P for interaction 0.010).

CONCLUSIONS

Our results revealed that heavier cigarette smoking was associated with a higher risk of ONFH. The elevated risk from cigarette smoking was markedly pronounced among those who had never used oral corticosteroids.

The role of hypercoagulability in the development of osteonecrosis of the femoral head

Despite the large number of the outstanding researches, pathogenesis of osteonecrosis remains unknown. During the last decades the hypothesis that increased intravascular coagulation may be the pathogenetic mechanism which leads to osteonecrosis is gaining constantly support. Both primary factors of hyper-coagulability, such as resistance to activated protein C, protein C and protein S deficiency, low levels of tissue plasminogen activator, high levels of plasminogen activator inhibitor, von Willebrand factor, lipoprotein (a), and secondary factors of hypercoagulability with factors potentially activating intravascular coagulation, such as pregnancy, antiphospholipid antibodies, systemic lupus erythematosus, hemoglobinopathies and sickle cell disease, and hemato-oncologic diseases are discussed in this article. Although coagulation abnormalities in patients with hip osteonecrosis might represent increased risk factors for the development of bone necrosis by predisposing the patient to thromboembolic phenomena, further investigation is needed to indicate the definite correlation between factors leading to increased intravascular coagulation and pathogenesis of osteonecrosis.

Avascular osteonecrosis and accompanying anemia, leucocytosis, and decreased bone mineral density in renal transplant recipients

BACKGROUND

Avascular osteonecrosis (AVN) is a complication of renal transplantation. In this study, we present 12 cases of AVN associated with renal transplantation.

METHODS

Renal transplant recipients (RTRs) with AVN (group I [GI]) were evaluated by using magnetic resonance imaging and blood urea nitrogen, creatinine, glucose, calcium, phosphorus, magnesium, alkaline phosphatase, parathyroid hormone, and urine analysis. We evaluated bone mineral density (BMD) of the femoral neck and lumbar vertebrae. All patients were treated with steroids, cyclosporine, or tacrolimus plus mycophenolate mofetil. Twenty-six RTRs (GII) without AVN were randomly selected as control subjects.

RESULTS

The mean ages of GI and GII, were 33.81 ± 6.72 and 34.00 ± 7.65 years respectively (P > .05). The mean interval between transplantation and development of AVN was 12.08 ± 6.48 months. Although levels of blood urea nitrogen, creatinine, calcium, magnesium, and parathyroidhormone, as well as glucocorticoid doses in the first 12 months were similar in GI and GII, there were significant differences in serum alkaline phosphatase, hemoglobin levels, and white blood cell count between GI and GII (P < .05 for each). BMD T score <-1.5 was observed in 8/9 GI and 15/26 patients in GII. All of the patients with AVN except 1, were followed with conservative measures including calcium, magnesium, and vitamin D replacement therapies, bisphosphonate, and reduced or ceased glucocorticoid treatment. Although T scores of the femoral head were similar in GI and GII, the lumbar vertebral T score was significantly lower in GI than in GII (P < .052).

CONCLUSION

AVN developed within the first year after transplantation. Decreased lumbar vertebral BMD, which can be an indicator of glucocorticoid effect, accompanied AVN in nearly all patients. Despite the absence of renal dysfunction, increased bone destruction, anemia, and leucocytosis were coincidental or accompanying findings in our patients with AVN.

Impact of oral corticosteroid use for idiopathic osteonecrosis of the femoral head: a nationwide multicenter case-control study in Japan

BACKGROUND

Previous studies on corticosteroid use and idiopathic osteonecrosis of the femoral head (ONF) have been conducted involving patients with systemic lupus erythematosus and renal transplantation, among other disorders, which make it possible only to compare high- and low-dose corticosteroids. The main objective here was to estimate the impact of oral corticosteroid use for idiopathic ONF compared to nonuse of corticosteroids. In addition, we investigated the relations between underlying medical conditions and idiopathic ONF.

METHODS

A nationwide multicenter case-control study was conducted in Japan. Cases were defined as patients who visited the cooperative orthopedic department after January 2002 and received a diagnosis of idiopathic ONF after the visit. For each case, up to five matched controls were selected from among patients without idiopathic ONF who consulted the same orthopedic department after the visit of the identified case. The matching conditions were sex, age (5-year age groups), and ethnicity. The subjects' demographic and anthropometric data and histories of medications, diseases, alcohol consumption, and smoking were collected by a structured self-administered questionnaire. A conditional logistic regression model was used to obtain the odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 73 cases and 250 matched controls completed the questionnaire. After adjustment for the potential confounders, the multivariate OR of oral corticosteroid use compared to nonuse was 20.3 (95% CI 6.73-61.5). Furthermore, a positive association of liver disease with idiopathic ONF was observed with marginal significance (multivariate OR 3.53, 95% CI 0.88-14.1) regardless of oral corticosteroid use, alcohol consumption, and smoking.

CONCLUSIONS

The current findings first revealed the impact of oral corticosteroid use for idiopathic ONF compared to nonuse. However, because the regimen of corticosteroid therapy (dose and duration) could not be assessed, further study is required. An independent role of liver disease was also suggested.

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.

Chemotherapy-associated osteonecrosis in cancer patients with solid tumours: a systematic review

Non-traumatic osteonecrosis of bone is recognized as a potential complication in solid-tumour cancer patients receiving treatment with cytotoxic chemotherapy. This review summarizes recent reports of osteonecrosis associated with chemotherapy in cancer patients, and describes the possible underlying pathophysiology and options available for its diagnosis, prevention and treatment. Fifty-four reported cases of non-traumatic osteonecrosis in adult patients with solid tumours receiving chemotherapy were identified by searching for reports in the medical literature. Osteonecrosis was observed most commonly in men receiving chemotherapy for testicular cancer. Osteonecrosis was also seen in patients receiving chemotherapy for breast, ovarian, small-cell lung cancer and osteosarcoma. Most patients had received corticosteroids, had femoral head involvement and had delayed onset of osteonecrosis. It appears that patients at higher risk for osteonecrosis with chemotherapy are identifiable. As the long-term survival of patients with solid tumours receiving chemotherapy increases, the prevalence of treatment-related osteonecrosis may also increase. Patients should be informed that osteonecrosis is a potential complication of cancer treatment. Measures to reduce risk should be taken, and patients should be monitored for early symptoms. Routine screening for chemotherapy-associated osteonecrosis is not recommended; however, a high index of clinical suspicion in patients at risk may allow for early intervention and preservation of the joints.

Total hip replacement in renal transplant patients

Avascular necrosis of the femoral head creates considerable morbidity in successful renal transplant recipients who are generally young and expect active lifestyles. Total hip replacement is considered the treatment of choice in these patients, but surgeons may be wary because of a supposed increase in the risk of infection and other complications. A review of the literature reveals that cemented hip arthroplasty provides good to excellent functional outcomes for renal transplant patients. Most authors have found that the risk of infection is not increased despite chronic immunosuppression, but the rates of general complications are and should be anticipated and treated. There is a high rate of early failure in these patients because of their young age and diffuse osteopenia as a result of secondary hyperparathyroidism related to the underlying renal disease and chronic steroid use. Recent studies have found that despite decreased bone stock in these patients, porous-coated prostheses are not contraindicated.

Promoter polymorphisms of the vascular endothelial growth factor gene is associated with an osteonecrosis of the femoral head in the Korean population

OBJECTIVE

Disruption of the vascular supply to the bone and subsequent hypoxia has been implicated in the pathogenesis of osteonecrosis of the femoral head (ONFH). Vascular endothelial growth factor (VEGF), a major inducer of angiogenesis, has been correlated with several pathological conditions, from inflammation to ischemic processes. A number of polymorphisms in the VEGF gene have been described as being associated with several diseases, such as diabetic retinopathy, prostate cancer and breast cancer. The aim of this study was to evaluate the association of VEGF gene polymorphisms with ONFH in a case--control study.

METHODS

Three polymorphisms (-2578C>A, -634G>C and +936C>T) in VEGF were genotyped in 317 ONFH patients and 497 control subjects, using the TaqMan 5' allelic discrimination assay. We performed the association analysis of genotyped single nucleotide polymorphisms (SNPs) and haplotypes with ONFH.

RESULTS

The -634G>C genotype was significantly associated with an increased risk for ONFH in dominant model with odds ratio (OR) of 1.47, 95% confidence intervals (CIs) 1.08-2.01 with P value 0.015. Further analysis stratified by sex showed that the -634G>C genotype was also significantly associated with a high risk for male patients considering the dominant model with OR of 1.60, 95% CI 1.13-2.26 with P value 0.008. Haplotype association analysis did not provide a further delineation of the risk allele.

CONCLUSION

Our study is, to our knowledge, the first report that shows the -634G>C polymorphism in the VEGF promoter was associated with an increased susceptibility of ONFH in the Korean population.

Symptomatic osteonecrosis of the hip and knee after cardiac transplantation

Patients who are treated with steroids for immunosuppression after solid organ transplant are at risk for development of osteonecrosis. The purpose of this study was to determine the prevalence of symptomatic osteonecrosis of the hip and knee in patients who were treated with corticosteroids after cardiac transplantation and to determine if there was a relationship between steroid dose and the development of osteonecrosis. We retrospectively evaluated 204 patients who underwent cardiac transplantation and noted that only 6 (3%) of 204 patients developed symptomatic osteonecrosis of the hip or knee. The osteonecrosis was diagnosed an average of 38.5 months (range, 21-52 months) after transplantation. There was no association noted between steroid dose and the development of symptomatic osteonecrosis. The low prevalence of osteonecrosis supports the hypothesis that the development of osteonecrosis in these patients is an idiosyncratic response to steroids, perhaps related to an underlying hypercoagulable state or hypofibrinolysis.

Osteonecrosis in stroke-prone spontaneously hypertensive rats: effect of glucocorticoid

BACKGROUND

High-dose administration of a steroid hormone has been associated with a major risk of osteonecrosis. In this study we investigated the effects of a steroid hormone on the incidence of osteonecrosis of the femoral head in stroke-prone spontaneously hypertensive rats/Nagasaki (SHRSP/Ngsks).

METHODS

A total of 71 SHRSP/Ngsks were divided into two groups: a control group (C group, n = 40) and a steroid hormone group (S group, n = 31) given 5 mg (about 20 mg/kg) of methylprednisolone acetate during the 17th week of age. We compared the groups' laboratory data, histological appearance, incidence of osteonecrosis, and expression of oxidative stress on immunohistochemical analysis using the monoclonal antibodies anti-4HNE and anti-8OHdG.

RESULTS

The S group showed an increase in total cholesterol, with the amounts of high-density lipoprotein, low-density lipoprotein, and triglycerides all significantly higher than in the C group. Histological examination showed that the frequency of necrosis of the femoral head was significantly higher in the S group (95.2%) than in the C group (51.2%). Most of the histological features of the osteonecrosis demonstrated typical features of a similar sort in the two groups. However, the S group showed bone marrow spaces in the femoral head that were occupied by an increased number of adipocytes and that were swollen, partially degenerative, and necrotic. On immunohistochemical analysis, the stains of anti-4HNE and anti-8OHdG antibody were stronger in the S group than in the C group.

CONCLUSIONS

This study confirmed, to a remarkable degree, the suspicion that the administration of steroid hormone increases the number of adipocytes in marrow. Fat degeneration and necrosis, considered early signs of osteonecrosis, were also observed. It has been hypothesized that osteonecrosis is produced by the ischemic change accompanying compartment pressure load in marrow, where fat degeneration, necrosis, and endothelial cell injury might occur together with oxidative stress.

From marrow oedema to osteonecrosis: common paths in the development of post-transplant bone pain

Osteonecrosis, the calcineurin-inhibitor-induced pain syndrome and transient marrow oedema may occur after renal transplantation, are generally painful and can be diagnosed by X-ray, radionuclide scan or magnetic resonance imaging. They share features of increased intraosseous pressure, compromised vascular supply, marrow oedema and the development of a 'bone compartment syndrome'. Glucocorticoid dosage is the most commonly implicated risk factor for osteonecrosis. Mechanisms may include the differentiation of mesenchymal stem cells to adipocytes causing increased intraosseous pressure and collapse of marrow sinusoids, as well as increased osteoblast and osteocyte apoptosis. Some of these effects may be ameliorated by lipid lowering drugs. Calcineurin-inhibitors, particularly cyclosporine, may increase the risk of osteonecrosis because of vasoconstrictive effects and sirolimus may influence the development of osteonecrosis by potentiating the effects of calcineurin inhibitors or by influencing the lipid profile. For osteonecrosis, early stages are generally managed conservatively or with core decompression sometimes accompanied by bone grafting and more recently the injection of bone morphogenic protein. The use of iloprost to improve blood flow and bisphosphonates and RANK-ligand inhibition to reduce osteoclastic resorption of remaining trabecular structures are as yet unproven strategies. Unfortunately, the rate of total hip arthroplasty remains high. For the calcineurin-inhibitor-induced pain syndrome and transient marrow oedema, calcium channel blockers, the reduction or withdrawal of calcineurin-inhibitors and core decompression have been used. Although a lack of randomized controlled trials makes management decisions difficult, early recognition of these bone pain syndromes affords the best opportunity for avoiding prolonged pain or joint replacement surgery.

Therapy Insight: orthopedic complications after solid organ transplantation in childhood

Several factors, such as immobilization, metabolic bone disease and immunosuppressive drugs, can compromise the quality of bone in children who have undergone solid organ transplantation. In contrast to adults, decreased bone mineral density has been reported in only a small proportion of pediatric transplant patients, and the relationship between low bone mineral density and fracture risk has not been established in children. Nevertheless, fractures, scoliosis, and joint and spinal degeneration are common in patients who received solid organ grafts as children. Avascular bone necrosis occurs infrequently in this patient population. Future studies should evaluate the effects of the underlying disease, transplantation and immunosuppression on the metabolism of bone and cartilage. On the basis of our own clinical experience and literature review, the growing spine of children who have received transplants should be continuously evaluated, and follow-up of bone mineral density is indicated. By contrast, routine MRI of the joints seems unnecessary.

Association of corticosteroids and factor V, prothrombin, and MTHFR gene mutations with avascular osteonecrosis in renal allograft recipients

The mechanism of posttransplantation avascular osteonecrosis (AVN) is controversial. Besides an increased bone marrow pressure due to reduced blood supply, enhanced coagulation has been considered. We investigated the associations of factor V Leiden, prothrombin G20210A, and MTHFR C677T mutations as well as cumulative corticosteroid doses with AVN in renal allograft recipients. The records of 39 volunteer patients and 11 patients in whom osteonecrosis was previously identified were reviewed for cumulative corticosteroid dosages during the first year. All patients were screened for factor V Leiden, prothrombin G20210A, and MTHFR C677T mutations by direct sequencing of genomic DNA. The cumulative corticosteroid dosages at 3, 6, and 12 months in the osteonecrotic group (5033.5 +/- 1565.3, 7164.9 +/- 2063.1, 8835.1 +/- 2216.8 mg) were significantly higher than in the control group (3629 +/- 1504.1, 4784.5 +/- 1568.7, 6322.4 +/- 1686.6 mg; P = .013, P = .001, P = .001, respectively). No significant difference in factor V Leiden, prothrombin G20210A, and MTHFR C677T mutations was observed between the osteonecrotic and control groups (P > .05). In conclusion, an association between the first year (3, 6, and 12 month) cumulative corticosteroid dosages and AVN was demonstrated in renal transplant recipients. However, no correlation was determined between factor V Leiden, prothrombin G20210A, and MTHFR C677T mutations and osteonecrosis.

Avascular Bone Necrosis of the Hip Joint after Solid Organ Transplantation in Childhood: A Clinical and MRI Analysis

BACKGROUND

Aseptic osteonecrosis is a well-known complication after solid organ transplantation in adults. The occurrence of osteonecrosis in growing age has been studied after kidney transplantation, but no systematic evaluation of the joints has been reported after heart or liver transplantation in childhood.

METHODS

A total of 196 children--93% of patients surviving kidney, liver and heart transplantation in Finland--participated in a cross-sectional survey. All children underwent a detailed clinical examination and filled out a questionnaire on musculoskeletal symptoms. Radiographs were taken in case of joint pain or abnormal clinical findings. In addition, magnetic resonance imaging (MRI) from the hips was taken on a random basis from 34 adult patients transplanted as a child. The mean follow-up time of all patients after transplantation was 9.2 years (range, 2.4 to 20.5 years).

RESULTS

Twenty-eight (14%) patients reported prolonged joint or limb pain without previous trauma. Specific etiology for the limb pain was not found in 10 (5.1%) patients. Osteonecrosis seen in radiographs or MRI was noted in seven (3.6%) patients, of which three had received kidney, three liver, and one heart graft. Femoral head was affected in five patients, as well as talus bilaterally in one patient and lateral femoral condyle in one patient. All patients were older than 12 years at the time of diagnosis of the osteonecrosis. MRI of the hips of 34 randomly selected patients showed only one asymptomatic necrosis of the femoral head.

CONCLUSIONS

Symptomatic osteonecrosis of the hip is uncommon after solid organ transplantation in childhood using the current immunosuppressive medications.

Nontraumatic osteonecrosis of the femoral head: ten years later

The etiology of osteonecrosis of the hip may have a genetic basis. The interaction between certain risk factors and a genetic predisposition may determine whether this disease will develop in a particular individual. The rationale for use of joint-sparing procedures in the treatment of this disease is based on radiographic measurements and findings with other imaging modalities. Early diagnosis and intervention prior to collapse of the femoral head is key to a successful outcome of joint-preserving procedures. The results of joint-preserving procedures are less satisfactory than the results of total hip arthroplasty for femoral heads that have already collapsed. New pharmacological measures as well as the use of growth and differentiation factors for the prevention and treatment of this disease may eventually alter our treatment approach, but it is necessary to await results of clinical research with long-term follow-up of these patients.

[Pain management in non-juvenile, aseptic osteonecrosis]

BACKGROUND

Adult aseptic osteonecrosis (ON) represents a clinical picture with unexplained etiology. Since curative treatment of this disease often succeeds only in the early stage, pain therapy plays an important role in the treatment process.

METHOD

We compared established and novel treatment options for ON as well as our own results after i.v. administration of the prostacyclin analogue iloprost with corresponding studies in the literature.

RESULTS

In addition to treatment with nonsteroidal antirheumatic agents and opioids, surgical "core decompression," vasoactive medications, and hyperbaric oxygenation are effective. Treatment with iloprost for 5 days resulted in highly significant pain reduction.

CONCLUSION

Symptomatic treatment is indicated in all stages of ON and curative treatment in stage I and early stage II. In cases of disease progression in the large joints, early endoprosthetic replacement is indicated to avoid secondary damage. In addition to employing vasoactive substances, a further curative treatment approach could be the use of mesenchymal stem cells.