Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 2: Alcohol-Associated Osteonecrosis

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study

PURPOSE

To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater.

METHODS

An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%.

RESULTS

Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration.

CONCLUSIONS

There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy.

LEVEL OF EVIDENCE

Level V, expert opinion.

Panoramic heat map for spatial distribution of necrotic lesions

Aims

In this study, we aimed to visualize the spatial distribution characteristics of femoral head necrosis using a novel measurement method.

Methods

We retrospectively collected CT imaging data of 108 hips with non-traumatic osteonecrosis of the femoral head from 76 consecutive patients (mean age 34.3 years (SD 8.1), 56.58% male (n = 43)) in two clinical centres. The femoral head was divided into 288 standard units (based on the orientation of units within the femoral head, designated as N[Superior], S[Inferior], E[Anterior], and W[Posterior]) using a new measurement system called the longitude and latitude division system (LLDS). A computer-aided design (CAD) measurement tool was also developed to visualize the measurement of the spatial location of necrotic lesions in CT images. Two orthopaedic surgeons independently performed measurements, and the results were used to draw 2D and 3D heat maps of spatial distribution of necrotic lesions in the femoral head, and for statistical analysis.

Results

The results showed that the LLDS has high inter-rater reliability. As illustrated by the heat map, the distribution of Japanese Investigation Committee (JIC) classification type C necrotic lesions exhibited clustering characteristics, with the lesions being concentrated in the northern and eastern regions, forming a hot zone (90% probability) centred on the N4-N6E2, N3-N6E units of outer ring blocks. Statistical results showed that the distribution difference between type C2 and type C1 was most significant in the E1 and E2 units and, combined with the heat map, indicated that the spatial distribution differences at N3-N6E1 and N1-N3E2 units are crucial in understanding type C1 and C2 necrotic lesions.

Conclusion

The LLDS can be used to accurately measure the spatial location of necrotic lesions and display their distribution characteristics.

Overexpression of miR-532-5p restrains oxidative stress response of chondrocytes in nontraumatic osteonecrosis of the femoral head by inhibiting ABL1

This study is to probe into the meaning of serum miR-532-5p in nontraumatic osteonecrosis of the femoral head (ONFH), and a molecular mechanism of miR-532-5p in the development of nontraumatic ONFH. This study enrolled 96 patients diagnosed with nontraumatic ONFH and 96 patients with femoral neck fracture. The levels of miR-532-5p, ABL1, MMP-3, MMP-13, and cleaved-caspase3 were determined. Radiographic progression was assessed by ARCO staging system. Visual analog scale (VAS) and Harris hip score (HHS) were employed for evaluation of the symptomatic severity of nontraumatic ONFH. Cell viability and apoptosis in chondrocytes isolated from clinical samples were investigated with CCK-8 and flow cytometry. The levels of lactic dehydrogenase (LDH), superoxide dismutase (SOD), and malondialdehyde (MDA), mitochondrial membrane potential (ΔΨm), and reactive oxygen species (ROS) were determined. miR-532-5p was downregulated in tissues and serum of patients with nontraumatic ONFH, negatively related with ARCO staging and VAS, and positively correlated with HHS. Cell apoptosis, LDH, MDA, and ROS strengthened, while cell viability, ΔΨm, and SOD reduced in chondrocytes of nontraumatic ONFH patients. ABL1 was upregulated in cartilage tissues from nontraumatic ONFH patients. miR-532-5p targeted ABL1, and overexpressed miR-532-5p alleviated nontraumatic ONFH-induced oxidative stress damage of chondrocytes by restraining ABL1. miR-532-5p ameliorated oxidative stress injury in nontraumatic ONFH by inhibiting ABL1.

Time elapsed from definitive diagnosis to surgery for osteonecrosis of the femoral head: a nationwide observational study in Japan

OBJECTIVES

This study documents the time elapsed from the diagnosis of osteonecrosis of the femoral head (ONFH) to surgery, exploring the factors that influence ONFH severity.

DESIGN

Retrospective observational study of a nationwide database.

SETTING

The Kaplan-Meier method with log-rank tests was applied to examine the period from definitive diagnosis of ONFH to surgery using any surgery as the end point. For bilateral cases, the date of the first surgery was the endpoint.

PARTICIPANTS

This study included 2074 ONFH cases registered in 34 university hospitals and highly specialised hospitals of the multicentre sentinel monitoring system of the Japanese Investigation Committee between 1997 and 2018.

MAIN OUTCOME MEASURE

The primary outcome was the time from diagnosis to surgery. The secondary outcome was the proportion of subjects remaining without surgery at 3, 6 and 9 months, and at 1, 2 and 5 years after diagnosis.

RESULTS

The median time to surgery was 9 months (IQR 4-22 months) after diagnosis of ONFH. The time to surgery was significantly shorter in the alcohol alone group and the combined corticosteroid and alcohol group than in the corticosteroid alone group (p=0.018 and p<0.001, respectively), in early stage ONFH with no or mild joint destruction (stages II and III, p<0.001), and with joint preserving surgery (p<0.001). The proportion without surgery was 75.8% at 3 months, 59.6% at 6 months, 48.2% at 9 months, 40.5% at 1 year, 22.2% at 2 years and 8.3% at 5 years.

CONCLUSION

ONFH has been considered to be an intractable disease that often requires surgical treatment, but the fact that surgery was performed in more than half of the patients within 9 months from diagnosis suggests severe disease with a significant clinical impact.

TRIAL REGISTRATION NUMBER

Chiba University ID1049.

Hip Arthroscopy Debridement Combined with Multiple Small-Diameter Fan-Shaped Low-Speed Drilling Decompression in the Treatment of Early and Middle Stage Osteonecrosis of the Femoral Head: 14 Years Follow-Up

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a disease that occurs frequently in young and middle-aged people. Because of its high disability rate, it affects the ability to work, so the early treatment of this disease is particularly important. This retrospective study aimed to evaluate the clinical efficacy of hip arthroscopy combined with multiple small-diameter fan-shaped low-speed drilling decompression (MSFLD) in treating early-mid stage ONFH (ARCO II-IIIA) compared to MSFLD, with at least 10-year follow-up.

METHODS

A total of 234 patients who underwent hip arthroscopy and MSFLD for ONFH from 1998 to 2012 were analyzed retrospectively. This study enrolled patients between 18 and 60 years old with ARCO stage II-III A, diagnosed clinically and through imaging, in accordance with the 2021 guidelines for the treatment of ONFH. Clinical data, including demographics, operation mode, BMI, pre- and postoperative Harris score, and femoral head survival rate, were collected. Patients were divided into hip arthroscopy + MSFLD and MSFLD groups based on the operation mode. The t-test was used to compare the postoperative efficacy, Harris scores, and survival rates of the femoral head between the two groups.

RESULTS

Among the 234 patients, 160 cases were followed up, including 92 cases in the hip arthroscopy + MSFLD group and 68 cases in MSFLD group, the follow-up rate was 68.38%, and the follow-up time was (10-22)14.11 ± 3.06 years. The Harris score (80.65 ± 6.29) in the hip arthroscopy + MSFLD group was significantly higher than that in the MSFLD group (p = 0.00), and the survival rate of femoral head (5-year survival rate was 84.78%, 10-year survival rate was 23.91%) was also higher than that in the MSFLD group (5-year survival rate was 63.24%, 10-year survival rate was 8.82%). The 5-year and 10-year survival rates of patients with ARCO II were 82.11% and 28.42%, which were better than 54% and 33% for ARCO III A. The femur head survival rate of alcoholic ONFH (5-year survival rate 61.54%, 10-year survival rate 9.23%) was significantly higher than that of other types of ONFH.

CONCLUSION

Clinical follow-up of at least 10 years suggests that hip arthroscopy combined with MSFLD is an effective treatment for early-mid stage ONFH, with good clinical effect and high survival rate of femoral head.

Comparison between osteonecrosis of the humeral and femoral heads - epidemiological analysis of the surgical trend using the nationwide claims database of the republic of Korea

BACKGROUNDS

The humeral head is the second most common site of osteonecrosis, after the femoral head. However, compared to osteonecrosis of the femoral head (ONFH), epidemiological information on osteonecrosis of the humeral head (ONHH) is scarce. We hypothesised that different biomechanical properties of the shoulder from the hip joint might present different epidemiological characteristics of ONHH from those of the ONFH. To evaluate epidemiological differences, we compared trends in the surgical treatment of ONHH and ONFH using the nationwide medical claims database of the Republic of Korea (ROK).

METHODS

We analysed epidemiological data from the Health Insurance Review and Assessment (HIRA) database of the ROK between 2008 and 2018. HIRA database contains almost all medical information in an anonymised form, including demographics, diagnoses, and types of surgical procedures, generated through healthcare practices in ROK. The annual incidence rates of ONHH and ONFH were calculated based on the total number of the general population. Demographics, annual incidence, and the proportion of post-traumatic osteonecrosis and surgical procedures were compared according to the anatomical site and the affected year.

RESULTS

The total number of patients treated for ONHH and ONFH during the study period was 1,028 and 66,260, respectively. Although the incidence of ONHH increased, it is a relatively rare disease compared to ONFH. ONHH occurred more frequently in females, while ONFH occurred predominantly in male patients (p < 0.001). Surgical treatment for ONHH was most frequently performed in older patients (63.7%), whereas middle-aged patients had the largest proportion of ONFH (48.9%, p < 0.001). The proportion of post-traumatic osteonecrosis was significantly higher in the ONHH (5.1%) than in the ONFH (1.9%, p < 0.001). Arthroplasty was performed more frequently in the ONHH (96.0%) than in the ONFH (92.9%, p < 0.001).

CONCLUSION

Despite the anatomical similarities between the hip and shoulder joints, the different biomechanical properties, such as weight-bearing functions, might cause epidemiological differences between ONHH and ONFH.

Updating Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH), a condition characterized by the presence of a necrotic bone lesion in the femoral head, is caused by a disruption in the blood supply. Its occurrence is more common in young and middle-aged adults and it is the main reason for performance of total hip arthroplasty in this age group. Its incidence is increasing along with increased use of glucocorticoids for management of adjuvant therapy for treatment of leukemia as well as organ transplantation and other myelogenous diseases. Current information on etiology and pathogenesis, as well as natural history, stage system, and treatments is provided in this review. A description of the Association Research Circulation Osseous (ARCO) criteria for classification of glucocorticoids- and alcohol-associated ONFH, 2019 ARCO staging system, and 2021 ARCO classification using computed tomography for the early stages of ONFH is also provided.

Computer-Assisted and Hip Arthroscopy for Avascular Necrosis of the Femoral Head With Femoroacetabular Impingement

Avascular necrosis of the femoral head with femoroacetabular impingement is a disabling disease. Without early treatment and intervention, its further development will even lead to hip osteoarthritis and hip dysfunction. This technical note aims to introduce a computer-assisted precise core decompression of the femoral head, followed by injection of platelet-rich plasma and bone marrow aspirate concentrate. Then, the autologous ipsilateral iliac bone is transplanted to the core decompression area. Thereafter, under hip arthroscopy, the injured glenoid lip of the hip joint is repaired, and the cam deformity of the femoral head/neck junction is polished and formed. The advantages of this technique include accurately locating the core decompression area, combined with autologous cells and bone transplantation, being able to delay the process of avascular necrosis of the femoral head, and evaluating articular cartilage injury, subchondral collapse, and guidance during reaming and curettage.

Decreased serum MMP-9 levels in patients with nontraumatic osteonecrosis of the femoral head

BACKGROUND

Matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinases-1 (TIMP-1) are involved in the pathological mechanism of osteonecrosis of the femoral head (ONFH). This study aimed to investigate the relationship of serum MMP-9, TIMP-1, and the MMP-9/TIMP-1 ratio with disease severity in patients with nontraumatic ONFH.

METHODS

Serum levels of MMP-9 and TIMP-1 among 102 nontraumatic ONFH patients and 96 healthy individuals were determined by enzyme-linked immunosorbent assay (ELISA). Imaging severity was determined using the FICAT classification system. The Harris hip score (HHS) and visual analogue scale (VAS) were used to evaluate clinical progress. The correlations of serum MMP-9 and TIMP-1 levels with imaging severity and clinical progress was evaluated statistically. The diagnostic value of MMP-9 for NONFH disease severity was evaluated by examining receiver operating characteristic (ROC) curves.

RESULTS

The serum MMP-9 levels and the MMP-9/TIMP-1 ratio were significantly increased in patients with ONFH compared to normal controls, and TIMP-1 levels did not differ between the two groups. Serum MMP-9 levels and the MMP-9/TIMP-1 ratio were positively correlated with FICAT stage and VAS and were negatively correlated with the HHS score. The ROC curve results indicated that MMP-9 could be used as a potential marker of nontraumatic ONFH imaging progression.

CONCLUSIONS

We hypothesize that increased MMP-9 expression and an imbalance in the MMP-9/TIMP-1 ratio play a role in the development of ONFH and are correlate with the severity of ONFH. The determination of MMP-9 can be a useful tool to assess the severity of the disease in patients with nontraumatic ONFH.

Relationship between the degree of subchondral collapse and articular surface irregularities in osteonecrosis of the femoral head

Articular surface irregularities are often observed in collapsed femoral heads with osteonecrosis, while the effects of the degree of collapse on the articular surface are poorly understood. We first macroscopically assessed the articular surface irregularities on 2-mm coronal slices obtained using high-resolution microcomputed tomography of 76 surgically resected femoral heads with osteonecrosis. These irregularities were observed in 68/76 femoral heads, mainly at the lateral boundary of the necrotic region. The mean degree of collapse was significantly larger for femoral heads with articular surface irregularities than for those without (p < 0.0001). Receiver operating characteristic analysis showed that the cutoff value for the degree of collapse in femoral heads with articular surface irregularities at the lateral boundary was 1.1 mm. Next, for femoral heads with <3-mm collapse (n = 28), articular surface irregularities were quantitatively assessed based on the number of automatically counted negative curvature points. Quantitative evaluation showed that the degree of collapse was positively correlated with the presence of articular surface irregularities (r = 0.95, p < 0.0001). Histological examination of articular cartilage above the necrotic region (n = 8) revealed cell necrosis in the calcified layer and abnormal cellular arrangement in the deep and middle layers. In conclusion, articular surface irregularities of the necrotic femoral head depended on the degree of collapse, and articular cartilage was already altered even in the absence of macroscopically determined gross irregularities.

Less sclerotic microarchitecture pattern with increased bone resorption in glucocorticoid-associated osteonecrosis of femoral head as compared to alcohol-associated osteonecrosis of femoral head

BACKGROUND

Glucocorticoid usage and alcohol abuse are the most widely accepted risk factors for nontraumatic osteonecrosis of femoral head (ONFH). Despite distinct etiologies between glucocorticoid-associated ONFH (GONFH) and alcohol-associated ONFH (AONFH), little is known about the differences of the microarchitectural and histomorphologic characteristics between these subtypes of ONFH.

PURPOSES

To investigate bone microarchitecture, bone remodeling activity and histomorphology characteristics of different regions in femoral heads between GONFH and AONFH.

METHODS

From September 2015 to October 2020, 85 patients diagnosed with GONFH and AONFH were recruited. Femoral heads were obtained after total hip replacement. Femoral head specimens were obtained from 42 patients (50 hips) with GONFH and 43 patients (50 hips) with AONFH. Micro-CT was utilized to assess the microstructure of 9 regions of interest (ROIs) in the femoral head. Along the supero-inferior orientation, the femoral head was divided into necrotic region, reactive interface, and normal region; along the medio-lateral orientation, the femoral head was divided into medial region, central region and lateral region. Decalcified and undecalcified bone histology was subsequently performed to evaluate histopathological alterations and bone remodeling levels.

RESULTS

In the necrotic region, most of the microarchitectural parameters did not differ significantly between GONFH and AONFH, whereas both the reactive interface and normal region revealed a less sclerotic microarchitecture but a higher bone remodeling level in GONFH than AONFH. Despite similar necrotic pathological manifestations, subchondral trabecular microfracture in the necrotic region was more severe and vasculature of the reactive interface was more abundant in GONFH.

CONCLUSIONS

GONFH and AONFH shared similar microarchitecture and histopathological features in the necrotic region, while GONFH exhibited a less sclerotic microarchitecture and a more active bone metabolic status in both the reactive interface and normal region. These differences between GONFH and AONFH in bone microarchitectural and histopathological characteristics might contribute to the development of disease-modifying prevention strategies and treatments for ONFH, taking into etiologies.

Trends in Surgical Treatment of Femoral Head Osteonecrosis in South Korea: An Analysis Using Nationwide Claims Database

BACKGROUND

Osteonecrosis of the femoral head (ONFH) involves young or middle-aged adults, and its incidence is increasing along with increasing use of steroids in the management of organ transplantation and adjuvant therapy for malignant neoplasms. To date, no pharmacological agent has been proven to prevent or retard the progression of ONFH, and surgical procedures including joint preservation procedures and hip arthroplasties are main treatments for the disease. Although ONFH is the most common or second most common disease for hip arthroplasty in East Asian countries, the trend of surgical procedures in this region remains unknown. Thus, we evaluated trends in surgical treatment of the disease in South Korea.

METHODS

We identified patients with ONFH from the Korean Health Insurance Review and Assessment (HIRA) database, a nationwide medical claims database of South Korea, between January 2007 and December 2018 and calculated the proportions of following surgical procedures at each year: total hip arthroplasty (THA), hemiarthroplasty (HA), core decompression/multiple drilling, femoral osteotomy, and vascularized bone grafting.

RESULTS

The total number of procedures increased from 3,824 in 2007 to 6,929 in 2018. Overall, the rate of THA (86%) was far greater than other procedures. From 2007 to 2018, the percentage of THA among the procedures increased from 80% to 91%, while that of joint preservation procedures decreased from 11% to 5%.

CONCLUSIONS

The total number of surgical procedures performed for ONFH increased and the percentage of THA increased, while that of joint preservation procedures decreased from 2007 to 2018 in South Korea.

Does Diabetes Mellitus Increase the Risk of Avascular Osteonecrosis? A Systematic Review and Meta-Analysis

Avascular osteonecrosis (AVN) is caused by the disrupted blood supply to the bone. Most AVN cases occur in the femoral head, but other sites might be affected as well, including the jaw or distal bones of the extremities. Previous studies suggested that diabetes could increase the risk of AVN of the jaw, but the relationship between diabetes and AVN in other bone sites is unclear. This systematic review and meta-analysis aimed to summarize the evidence from studies that had reported on the occurrence of AVN in sites other than the jaw, depending on the diagnosis of diabetes. Overall, we included 6 observational studies carried out in different populations: primary or secondary AVN of the femoral head, Takayasu arteritis, general population, kidney transplant recipients, systemic lupus erythematosus, and primary brain tumors. A random-effects meta-analysis showed that the risk of AVN in sites other than the jaw was non-significantly increased in patients with diabetes (odds ratio: 1.90, 95% confidence interval: 0.93-3.91). The pooled estimate increased and was significant after the exclusion of one study (2.46, 1.14-5.32). There was a significant heterogeneity (I² = 65%, tau² = 0.48, p = 0.01; prediction interval, 0.21-16.84). There was no significant publication bias (p = 0.432). In conclusion, diabetes could increase the risk of AVN in sites other than the jaw, but the available evidence is limited. There is a need for large, well-designed, population-based studies.

Imbalanced T-Cell Subsets May Facilitate the Occurrence of Osteonecrosis of the Femoral Head

Background

Osteonecrosis of the femoral head (ONFH) is a complex disease resulting in degeneration of the hip joint. The pathogenesis of ONFH is largely unknown, but alterations in immunological factors have been proposed to play a role.

Methods

We included 109 patients with ONFH and 109 age-, sex-, and body mass index-matched healthy controls in this study. The percentage of circulating CD3+, CD4+, and CD8+ lymphocytes among the total lymphocytes was identified by flow cytometry and compared between the cases and controls. Subgroup analysis within each etiological group and correlation analysis of T-cell subset levels with disease duration were performed. Furthermore, we compared the expression patterns of CD4, RANKL, and FoxP3 in the femoral head of healthy and glucocorticoid (GC)-treated ONFH rats.

Results

The results showed that CD3+ and CD4+ T-cell counts and the CD4+/CD8+ ratio were significantly higher in patients with ONFH and that CD3+ lymphocyte levels were negatively correlated with disease duration. The CD4+ T-cell levels and CD4+/CD8+ ratios in the GC-ONFH etiological group were lower than those in the idiopathic-, traumatic-, and alcoholic-ONFH groups, while the CD8+ T-cell levels were higher. Furthermore, the CD3+, CD4+, and CD8+ T-cell counts and the CD4+/CD8+ ratio were higher in the GC-ONFH group than in the control group. Finally, we observed diminished levels of FoxP3/CD4 double-positive T regulatory cells and increased RANKL+ T-cell levels in the bone marrow of the femoral head in GC-ONFH rats.

Conclusion

The imbalance of T-cell subsets might be involved in the pathophysiological process of ONFH, and diminished CD4+/FoxP3+ T regulatory cells may be associated with increased RANKL+ T cells in the bone marrow of the femoral head in GC-ONFH, which may facilitate bone resorption and collapse of the femoral head.

Trial Registration

This study was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2100042642).

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study

BACKGROUND

The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications.

METHODS

In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH.

RESULTS

In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10^-5).

CONCLUSION

This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Activation of aldehyde dehydrogenase 2 protects ethanol-induced osteonecrosis of the femoral head in rat model

OBJECTIVES

Osteonecrosis of the femoral head (ONFH) is a devastating disease characterized by destructive bone structures, enlarged adipocyte accumulation and impaired vascularization. The aldehyde dehydrogenase 2 (ALDH 2) is the limiting enzyme for ethanol metabolism with many physiological functions. The aim was investigated the potential protective role of activated ALDH 2 by Alda-1 for ethanol-induced ONFH.

MATERIALS AND METHODS

The ethanol-induced ONFH in rat was performed to explore the protective of Alda-1 by various experimental methods. Subsequently, the effect of Alda-1 and ethanol on the osteogenic and adipogenic differentiation was investigated via multiple cellular and molecular methods. Finally, the effect of Alda-1 and ethanol on the neo-vascularization was detected in Human umbilical vein endothelial cells (HUVECs) and ONFH model.

RESULTS

Firstly, radiographical and pathological measurements indicated that alda-1 protected ethanol-induced ONFH. Moreover, ethanol significantly inhibited the proliferation and osteogenic differentiation of BMSCs, whereas Alda-1 could distinctly rescue it by PI3K/AKT signalling. Secondly, ethanol remarkably promoted the lipid vacuoles formation of BMSCs, while Alda-1 significantly retarded it on BMSCs by AMPK signalling pathway. Finally, ethanol significantly inhibited proliferation and growth factor level resulting in reduced angiogenesis, whereas Alda-1 could rescue the effect of ethanol. Additionally, Alda-1 significantly reduced the occurrence of ONFH and promoted vessel number and distribution in alcoholic ONFH.

CONCLUSIONS

Alda-1 activation of ALDH 2 was highly demonstrated to protect ethanol-induced ONFH by triggering new bone formation, reducing adipogenesis and stimulating vascularization.

Treatment of non-traumatic avascular necrosis of the femoral head (Review)

Non-traumatic osteonecrosis of the femoral head is the main cause of disability in young individuals and incurs major health care expenditure. The lifestyle changes in recent years, especially increased use of hormones and alcohol consumption, has greatly increased the incidence of femoral head necrosis. The underlying causes and risk factors of osteonecrosis of the femoral head are increasingly being elucidated, which has led to the development of novel surgical and non-surgical treatment options. Although the main goal of any treatment method is prevention and delaying the progression of disease, there is no common consensus on the most suitable method of treatment. The present review discussed the latest developments in the etiology and treatment methods for femoral head necrosis.

Third-Generation Ceramic-on-Ceramic Total Hip Arthroplasty in Patients with Osteonecrosis of the Femoral Head: A 10- to 16-year Follow-up Study

BACKGROUND

Long-term follow-up results of ceramic-on-ceramic (COC) total hip arthroplasty (THA), specifically, in patients with osteonecrosis of the femoral head (ONFH) are unknown. We evaluated (1) clinical results and radiological outcomes, (2) ceramic-related complications: noise and ceramic fracture, (3) osteolysis, and (4) survivorship after alumina COC THA in ONFH patients with longer than 10-year follow-up.

METHODS

From May 2003 to June 2009, 325 ONFH patients (403 hips) underwent primary THAs at our department. Among them, 231 patients (293 THAs) were followed for 10 to 16 (mean, 12.9) years. There were 148 men and 83 women, their mean age at the time of THA was 47.2 years, and their mean body index was 24.0 kg/m2. The postoperative CT scans were done in 160 hips.

RESULTS

Grinding sensation or squeak was noted in 6.8% (20/293), ceramic head fracture occurred in 2.4% (7/293) and acetabular osteolysis developed in 0.7% (2/293). All 7 ceramic fractures occurred in 28-mm short-neck heads. There was no detectable wear or prosthetic loosening, and the 16-year survivorship was 96.0% (95% confidence interval; 93.8% to 98.2%). The mean Harris hip score was 91.7 (range, 84 to 100) points at the final follow-up.

CONCLUSIONS

The 10- to 16-year results of alumina COC THAs were encouraging with an excellent survivorship. However, ceramic fracture and noise still remain matters of concern. We recommend not to use 28-mm short-neck ceramic head to avoid ceramic head fractures.

LEVEL OF EVIDENCE

III.

Abnormal Lipid Profiles in Nontraumatic Osteonecrosis of the Femoral Head: A Comparison with Osteoarthritis Using Propensity Score Matching

BACKGROUND

Abnormal lipid metabolism may play an important role in the development of nontraumatic osteonecrosis of the femoral head (ON). By comparing lipid biomarkers in patients with ON and osteoarthritis (OA) after propensity score matching, we sought to reveal (1) common lipid biomarkers that are abnormal in ON regardless of the etiology and (2) specific lipid biomarkers associated with ON according to the etiology.

METHODS

Among 2,268 patients who underwent primary THA, 1,021 patients were eligible for this study. According to the Association Research Circulation Osseous criteria, ON was classified as either idiopathic (n = 230), alcohol-associated (n = 293), or glucocorticoid-associated ON (n = 132). Most common cause of OA was hip dysplasia in 106 patients (47%). We investigated patient lipid profiles by assessing total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), apolipoprotein (Apo) A1 and B, lipoprotein (a) levels and ApoB/A1 ratio. Since age and body mass index affect the lipid profile, we performed propensity score matching to select 304 patients for final analysis and compared lipid profiles between the ON and OA groups. We also compared biomarkers between the ON subgroups and the OA group.

RESULTS

Overall, the ON group showed lower HDL-C (p < 0.001), higher TGs (p = 0.001) levels and higher ApoB/A1 ratio (p = 0.003). Idiopathic ON patients demonstrated lower HDL-C (p = 0.032), higher TGs (p = 0.016), ApoB (p = 0.024) levels and ApoB/A1 ratio (p = 0.008). The alcohol-associated ON subgroup showed lower HDL-C (p < 0.001), higher TGs (p = 0.010) levels and ApoB/A1 ratio (p = 0.030). Finally, the steroid-associated ON subgroup demonstrated lower HDL-C (p = 0.003), higher TGs (p = 0.039), lower TC (p = 0.022), LDL-C (p = 0.021), and ApoA1 (p = 0.004) levels.

CONCLUSIONS

Higher TGs and lower HDL-C levels were associated with nontraumatic ON regardless of the etiology. Additionally, idiopathic ON was associated with higher ApoB levels and ApoB/A1 ratio. Alcohol-associated ON was related to higher ApoB/A1 ratio, and steroid-associated ON paired with decreased TC, LDL-C, and ApoA1 levels. Our findings may support future efforts for prevention and management of nontraumatic ON.

LEVEL OF EVIDENCE

Diagnostic Level III.

Cementless Hip Arthroplasty in Patients with Subchondral Insufficiency Fracture of the Femoral Head

BACKGROUND

Subchondral insufficiency fracture of the femoral head (SIFFH) occurs in elderly patients and might be confused with osteonecrosis of the femoral head (ONFH). Subchondral insufficiency fracture of the femoral head is an insufficiency fracture at the dome of the femoral head and has been known to be associated with osteoporosis, hip dysplasia, and posterior pelvic tilt. This study's aims were to evaluate (1) surgical complications, (2) radiological changes, (3) clinical results, and (4) survivorship of THA in patients with SIFFH.

METHODS

From November 2010 to June 2017, 21 patients (23 hips); 5 men (5 hips) and 16 women (18 hips) underwent cementless THA due to SIFFH at our institution. Their mean age was 71.9 years (range, 57 to 86) at the time of surgery, and mean T-score was -2.2 (range, -4.2 to 0.2). The mean lateral center-edge angle, abduction, and anteversion of the acetabulum were 29.9° (range, 14.8° to 47.5°), 38.5° (range, 31° to 45°), and 20.0° (range, 12° to 25°), respectively. The mean pelvic incidence, lumbar kyphotic angle and posterior pelvic tilt were 56.4° (range, 39° to 79°), 14.7° (range, -34° to 43°), and 13.0° (range, 3° to 34°), respectively.

RESULTS

An intraoperative calcar crack occurred in 1 hip. The mean anteversion and abduction of cup were 29.0° (range, 17° to 43°) and 43.3° (range, 37° to 50°), respectively. One patient sustained a traumatic posterior hip dislocation 2 weeks after the procedure, and was treated with open reduction. At a mean follow-up of 35.4 months (range, 24 to 79 months), no hip had prosthetic loosening or focal osteolysis. At the latest follow-up, the mean modified Harris hip score was 79.1 (range, 60 to 100) points, and mean UCLA activity score was 4.2 (range, 2 to 7) points. The survivorship was 95.7% (95% CI, 94.9% to 100%) at 6 years.

CONCLUSIONS

Cementless THA is a favorable treatment option for SIFFH in elderly patients.

LEVEL OF EVIDENCE

3.

Geographic distribution of the incidence of osteonecrosis of the femoral head in Japan and its relation to smoking prevalence

OBJECTIVES

Alcohol intake and smoking are modifiable lifestyle-related risk factors for osteonecrosis of the femoral head (ONFH). We investigated geographic differences in ONFH incidence in Japan and the correlation with alcohol intake and smoking to develop prevention strategies for ONFH in Japan.

METHODS

This ecological study was conducted in Japan primarily using the following data sources: nationwide epidemiological survey and national survey. We estimated the annual ONFH incidence and the prevalence of alcohol drinking and smoking in each prefecture. Prefectural incidence and prevalence were calculated by sex and age-standardization.

RESULTS

The mean annual ONFH incidence per 100,000 population was 3.08 in men and 1.63 in women, respectively. There was no significant correlation between ONFH incidence and the prevalence of any levels of alcohol intake, while smoking ≥20 cigarettes/day showed a significant and moderate correlation in men (r = 0.47, p = .01). This correlation remained significant after adjustment for the prevalence of any levels of alcohol intake (standardized partial regression coefficient = 0.47-0.49, p = .009-.01).

CONCLUSION

ONFH incidence is geographically variable in Japan, and this may be partly explained by the distribution of smoking prevalence. Smoking cessation may contribute to an effective decline in the overall ONFH incidence in Japan.

Lack of Conclusive Evidence of the Benefit of Biologic Augmentation in Core Decompression for Nontraumatic Osteonecrosis of the Femoral Head: A Systematic Review

PURPOSE

To assess whether biologic augmentation in addition to core decompression (CD), compared with CD alone, improves clinical and radiographic outcomes in the treatment of nontraumatic osteonecrosis of the femoral head (ONFH). Our hypothesis was that biologic augmentation would reduce the progression of osteonecrosis and therefore also the rate of conversion to total hip arthroplasty (THA).

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement. Six databases were searched: Central, MEDLINE, Embase, Scopus, AMED, and Web of Science. Studies comparing outcomes of CD versus CD plus biologic augmentation (with or without structural augmentation), with a reported minimum level of evidence of III and ≥24 months of follow-up, were eligible. Procedural success was conceptualized as (1) avoidance of conversion to THA and (2) absence of radiographic disease progression. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklists. A quantitative analysis of heterogeneity was undertaken.

RESULTS

We included studies reporting on 560 hips in 484 patients. Biologic augmentation consisted of bone marrow stem cells in 10 studies, bone morphogenic protein in 2, and platelet-rich plasma in 1. Three studies used additional structural augmentation. The median maximum follow-up time was 45 months. Only 4 studies reported improvement in all clinical scores in the augmentation group. Seven studies observed a reduction in the rate of radiographic progression, and only 5 found reduced rates of conversion to THA when using augmentation. A high risk of bias and marked heterogeneity was found, with uncertainty about the study designs implemented, analytical approaches, and quality of reporting.

CONCLUSION

Current evidence is inconclusive regarding the benefit of biologic augmentation in CD for nontraumatic ONFH, because of inconsistent results with substantial heterogeneity and high risk of bias.

LEVEL OF EVIDENCE

III, systematic review of level I, II, and III studies.

Geographical distribution of the associated factors of osteonecrosis of the femoral head, using the designated intractable disease database in Japan

OBJECTIVES

Osteonecrosis of the femoral head (ONFH) is a designated intractable disease (DID) in Japan. The Ministry of Health, Labour, and Welfare launched an online registry system for DIDs. We aimed to investigate the epidemiological characteristics of patients with ONFH using the DID database.

METHODS

Data of patients with ONFH registered in the DID database between January 2004 and December 2013 were extracted. The incidence of new cases and distributions of sex, age, and associated risk factors were investigated. The prevalence of the two categories, 'steroid-associated' and 'alcohol-associated' risk factors, was estimated for each prefecture.

RESULTS

New 15,049 cases of ONFH were investigated. The mean registration rate-corrected annual ONFH incidence per 100,000 individuals was 1.77. The male-to-female ratio was 1.33. Age distribution peaked in the 40s and 50s for male and 60s for female. The prevalence of steroid-associated ONFH was lower in males (28.6%) than in females (49.8%), while that of alcohol-associated ONFH was higher in males (47.2%) than in females (9.3%). No clear region was identified for the steroids. The incidence of alcohol-associated ONFH was significantly higher in Tokyo and Okinawa, regardless of sex.

CONCLUSIONS

Alcohol-associated ONFH incidence varies geographically across Japan, suggesting that it has regional characteristics.

Risk factors for multi-joint disease in patients with glucocorticoid-induced osteonecrosis

This study investigated risk factors for osteonecrosis involving multiple joints (MJON) among glucocorticoid-treated patients. The best predictor of MJON was cumulative oral glucocorticoid dose. Risk of MJON was 12-fold higher in patients who had a second risk factor for osteonecrosis. Further research is needed into strategies for prevention of MJON.

INTRODUCTION

Osteonecrosis (ON) is a debilitating musculoskeletal condition in which bone cell death can lead to mechanical failure. When multiple joints are affected, pain and disability are compounded. Glucocorticoid treatment is one of the most common predisposing factors for ON. This study investigated risk factors for ON involving multiple joints (MJON) among glucocorticoid-treated patients.

METHODS

Fifty-five adults with glucocorticoid-induced ON were prospectively enrolled. MJON was defined as ON in ≥ three joints. Route, dose, duration, and timing of glucocorticoid treatment were assessed.

RESULTS

Mean age of enrolled subjects was 44 years, 58% were women. Half had underlying conditions associated with increased ON risk: systemic lupus erythematosus (29%), acute lymphoblastic leukemia (11%), HIV (9%), and alcohol use (4%). Mean daily oral dose of glucocorticoids was 29 mg. Average cumulative oral dose was 30 g over 5 years. The best predictor of MJON was cumulative oral glucocorticoid dose. For each increase of 1,000 mg, risk of MJON increased by 3.2% (95% CI 1.03, 1.67). Glucocorticoid exposure in the first 6 months of therapy, peak dose (oral or IV), and mean daily dose did not independently increase risk of MJON. The risk of MJON was 12-fold in patients who had a second risk factor (95% CI 3.2, 44.4).

CONCLUSIONS

Among patients with glucocorticoid-induced ON, cumulative oral dose was the best predictor of multi-joint disease; initial doses of IV and oral glucocorticoids did not independently increase risk. Further research is needed to better define optimal strategies for prevention and treatment of MJON.

Epidemiological study of osteonecrosis of the femoral head using the national registry of designated intractable diseases in Japan

OBJECTIVES

We aimed to investigate the epidemiological characteristics of osteonecrosis of the femoral head (ONFH) using the designated intractable diseases (DID) database in Japan.

METHODS

Data on patients who had received public subsidies for medical costs due to ONFH from 2012 to 2013 were extracted from the DID database. The incidence and prevalence of ONFH, distribution of gender, age, and the prevalence of associated risk factors were assessed. These epidemiological characteristics were compared with those of another nationwide ONFH survey conducted during a similar period.

RESULTS

Data on 3264 newly diagnosed patients (incident cases) and 20,042 patients registered until 2013 (prevalent cases) were evaluated. The corrected annual incidence and prevalence of ONFH per 100,000 were 3.0 and 18.2-19.2, respectively. The ratio of males to females was 1.4 in 2012 and 1.2 in 2013, respectively. Peak distribution was observed at ages 40s and 60s in males and females, respectively. The prevalence of the risk factors were steroid-associated: 39%, alcohol-associated: 30%, both: 4%, and none: 27%.

CONCLUSIONS

The DID database data showed a similar distribution of gender and age to that in other nationwide surveys but lower incidence and prevalence of ONFH. Sampling bias may affect the epidemiological characteristics of ONFH.

Treatment of pre-collapse non-traumatic osteonecrosis of the femoral head through Orthopdische Chirurgie München approach combined with autologous bone mixed with β-tricalcium phosphate porous bioceramic bone graft: a retrospective study of mid-term results

Background

This study aimed to evaluate the clinical efficacy of femoral head and neck fenestration combined with autologous bone mixed with β-tricalcium phosphate porous bioceramic bone (light bulb procedure) through Orthopdische Chirurgie München approach (OCM approach) for pre-collapse non-traumatic osteonecrosis of the femoral head(ONFH).

Methods

The clinical data of 47 patients (47 hips) with ONFH were retrospectively reviewed. The Harris hip score (HHS) was used to evaluate the clinical outcomes. Imaging was assessed by X-ray. Clinical failure was defined as postoperative total hip arthroplasty (THA) or the HHS was poor (< 70). The Kaplan–Meier survival curve was used to conduct a univariate analysis of risk factors. The analysis factors included gender, age, International Association Research Circulation Osseous (ARCO) stage, etiology, body mass index (BMI), 25-hydroxyvitamin D (25(OH)D), and type I collagen carboxy-terminal peptide (CTX). The COX multivariate risk model was used to analyze the risk factors.

Results

All the 47 hips were followed up for 24–58 months, with an average of 45 months. The Harris score (76.29 ± 10.38) at the last follow-up was significantly higher than the preoperative HHS (64.45 ± 2.93) (P < 0.05). The postoperative HHS was excellent with a success rate of 36.17%. Postoperative imaging evaluation showed that 9 hips improved, 28 hips stabilized, and 10 hips progressed. Moreover, 17 out of 47 hips were defined as a postoperative clinical failure and the success rate was 63.83%. 25(OH)D and preoperative ARCO stage were risk factors for postoperative clinical failure (P < 0.05). The COX multivariate risk model analysis showed that IIIA stage was an independent risk factor for postoperative clinical failure (P < 0.05).

Conclusions

The head and neck fenestration and bone grafting via the OCM approach in the treatment of non-traumatic ONFH in the pre-collapse stage can achieve good clinical outcomes. 25(OH)D deficient patients and ARCO IIIA patients had a higher failure rate of bone graft using this approach.

Effect of L3MBTL3/PTPN9 polymorphisms on risk to alcohol-induced ONFH in Chinese Han population

PURPOSE

Alcohol-induced osteonecrosis femoral head necrosis (ONFH) is a disease that seriously affects human health. Abnormal expression of L3MBTL3/PTPN9 gene can cause a variety of human diseases. The purpose of this study is to investigate the effect of L3MBTL3/PTPN9 gene polymorphism on the susceptibility of alcohol-induced ONFH in Chinese Han population.

METHODS

A total of 308 alcohol-induced ONFH patients and 425 healthy controls were enrolled in this case-control study. Alleles, genotypes, genetic models, haplotypes, and multifactor dimensionality reduction analyses (MDR) based on age-corrected by using odds ratio (OR) and 95% confidence interval (CI) were performed.

RESULTS

Our result revealed rs2068957 in the L3MBTL3 gene increased the risk of alcohol ONFH under the recessive model after correction. Besides, we also found that rs75393192 in the PTPN9 gene was a protective site in stratification over 40 years of age and stage. In stratified analysis of necrotic sites, we only found that rs2068957 was associated with increased susceptibility of alcohol-induced ONFH under the co-dominant model and recessive model. Haplotype "GC" in the block (rs76107647|rs10851882 in PTPN9 gene) significantly decreased the susceptibility of alcoholic ONFH.

CONCLUSIONS

Our results provide evidence that L3MBTL3/PTPN9 polymorphisms are associated with alcohol-induced ONFH risk in Chinese Han population.

RAB40C Gene Polymorphisms Were Associated with Alcohol-Induced Osteonecrosis of the Femoral Head

Introduction

Alcohol-induced osteonecrosis of the femoral head (ONFH), a progressive disease, is caused by excessive drinking and genetic factors. Currently, it remains to represent a significant challenge. The association between alcohol-induced ONFH and RAB40C gene polymorphisms may provide a direction for the mechanism of alcoholic ONFH.

Methods

A total of 201 alcohol-induced ONFH patients and 201 healthy controls were recruited in this case–control study. The polymorphisms of RAB40C gene were genotyped in blood samples by Agena MassARRAY RS1000. Pearson chi-square test was used to calculate difference in allele frequencies of gene polymorphisms between the cases and controls. Alcohol-induced ONFH risk was estimated using odds ratios (ORs) and 95% confidence intervals (CIs).

Results

In the overall analysis, the allele “G” of rs62030917 was significantly increased alcohol-induced ONFH risk (OR = 1.47, 95% CI = 1.07–2.02, p = 0.017) in the allele model. In the genetic analysis, rs62030917 also increased the risk of alcohol-induced ONFH in the dominant model (adjusted OR = 1.52, 95% CI=1.02–2.26, p = 0.039) and the log-additive model (adjusted OR = 1.42, 95% CI=1.05–1.93, p = 0.025). Age stratification analysis suggested that rs62030917 increased the risk of alcohol-induced ONFH among the individuals younger than 42 years old. Moreover, carriers of AA, GA and GG genotypes in rs2269556 had LDL-C levels that were significantly different (p = 0.047). Among them, carriers of GG genotype had the highest LDL-C levels.

Conclusion

This study revealed rs62030917 in RAB40C gene might increase the risk of alcohol-induced ONFH, providing a theoretical basis for the mechanism of RAB40C in alcohol-induced ONFH.

DNA methylation in the OPG/RANK/RANKL pathway is associated with steroid-induced osteonecrosis of the femoral head

BACKGROUND

Dysregulation of the OPG/RANK/RANKL signalling pathway is a key step in the occurrence of steroid-induced osteonecrosis of the femoral head (ONFH). This study aims to understand the degree of methylation of the OPG, RANK, and RANKL genes in steroid-related ONFH.

METHODS

A case-control study was designed, including 50 patients (25 males and 25 females) and 50 matched controls. The European Molecular Biology Open Software Suite (EMBOSS) was used to predict the existence and location of CpG islands in the OPG, RANK, and RANKL genes. The Agena MassARRAY platform was used to detect the methylation status of the above genes in the blood of subjects. The relationship between the methylation level of CpG sites in each gene and steroid-related ONFH was analysed by the chi-square test, logistic regression analysis, and other statistical methods.

RESULTS

In the CpG islands of the OPG, RANK, and RANKL genes in patients with steroid-related ONFH, several CpG sites with high methylation rates and high methylation levels were found. Some hypermethylated CpG sites increase the risk of steroid-related ONFH. In addition, a few hypermethylated CpG sites have predictive value for the early diagnosis of steroid-related ONFH.

CONCLUSION

Methylation of certain sites in the OPG/RANK/RANKL signalling pathway increases the risk of steroid-related ONFH. Some hypermethylated CpG sites may be used as early prediction and diagnostic targets for steroid-related ONFH.

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

Idiopathic arteriopathy-induced focal osteonecrosis of the femoral head in a young dog

CASE DESCRIPTION

A 15-month-old 6.5-kg (14.3-lb) castrated male mixed-breed dog was evaluated because of a 4-month history of progressive intermittent non-weight-bearing lameness of the left pelvic limb.

CLINICAL FINDINGS

Orthogonal radiography of the hip joints revealed a 4-mm atypical radiolucent lesion on the distal caudomedial aspect of the left femoral head and a disproportionately large-diameter femoral medullary canal with a low canal flare index. Prolonged unresponsiveness to medical management and progressive enlargement of the lesion prompted the recommendation for total hip replacement (THR).

TREATMENT AND OUTCOME

THR was performed to restore pain-free function of the left pelvic limb and normal activity. A circular osteochondral flap was grossly evident on the femoral head. Histopathologic findings for this portion of the bone indicated an arteriopathy-induced focal subchondral osteonecrosis that had resulted in articular surface collapse. The noted idiopathic arteriopathy had disrupted the normal blood supply to the affected area. On reexamination and radiographic evaluation 13 months after THR, the dog appeared to have pain-free function of the affected limb and had returned to normal activity with no reported complications or problems.

CLINICAL RELEVANCE

To the authors' knowledge, this report represented the first description of arteriopathy-induced focal osteonecrosis of the caudomedial aspect of the femoral head and its successful treatment in a young dog. This type of lesion may more commonly be the cause of hip joint osteoarthritis in young dogs than previously recognized because establishing a definitive diagnosis requires early recognition and histologic evaluation before advanced degenerative changes develop that obscure the underlying etiology.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Outcomes of Cemented Total Knee Arthroplasty for Secondary Osteonecrosis of the Knee

BACKGROUND

Secondary osteonecrosis of the knee (SOK) generally occurs in relatively young patients; at advanced stages of SOK, the only viable surgical option is total knee arthroplasty (TKA). We conducted a retrospective study to investigate implant survivorship, clinical and radiographic outcomes, and complications of contemporary cemented bicompartmental TKA with/without patellar resurfacing for SOK.

METHODS

Thirty-eight cemented TKAs in 27 patients with atraumatic SOK, mean age 43 years (17 to 65), were retrospectively reviewed. Seventy-four percent had a history of corticosteroid use, and 18% had a history of alcohol abuse. Patellar osteonecrosis was coincidentally found in six knees (16%), and all were asymptomatic without joint collapse. The mean followup was 7 years (2 to 12). Knee Society Score (KSS) and radiographic outcomes were evaluated at 6 weeks, 1 year, then every 2 to 3 years.

RESULTS

Ninety-two percent had implant survivorship free from revision with significant improvement in KSS. Causes of revision included aseptic tibial loosening (one), deep infection (one), and instability with patellofemoral issues (one). Four of six cases also with patellar osteonecrosis received resurfacing, including one with periprosthetic patellar fracture after minor trauma, with satisfactory clinical results after conservative treatment. None of the unrevised knees had progressive radiolucent lines or evidence of loosening. An unresurfaced patella, use of a stem extension or a varus-valgus constrained prosthesis constituted 18%, 8% and 3%, respectively.

CONCLUSION

Cemented TKAs with selective stem extension in patients with SOK had satisfactory implant survivorship and reliable outcomes. Secondary osteonecrosis of the patella should be carefully evaluated prior to operation.

Initial Presentation and Progression of Secondary Osteonecrosis of the Knee

BACKGROUND

Early detection and intervention are critical to maintaining the native articular cartilage before collapse in secondary osteonecrosis of the knee (SOK). We conducted a retrospective study documenting the initial stage of presentation and the progression of SOK.

METHODS

Our database was reviewed for patients younger than 65 years of age diagnosed with atraumatic SOK between 2002 and 2018. Demographic data, plain radiographs as well as MRI at initial evaluation, and initial treatment were classified and analyzed.

RESULTS

One hundred four patients with 164 knees were identified. Mean age was 39 ± 16 years. Females (64%) with bilateral disease (58%) predominated. Seventy-five percent of patients had a history of corticosteroid use, of which 41% were diagnosed with hematologic malignancy and lupus. Fifteen percent of patients had a history of ethanol abuse. At initial presentation, 55% of patients were diagnosed with Ficat-Arlet stage I/II, while 45% were diagnosed with Ficat-Arlet stage III/IV. We found a significant difference in the mean age of patients at early stage of SOK with corticosteroid use (31 ± 12 years of age) when compared to ethanol use (43 ± 13 years of age, P = .02). Treatments included observation (57%), joint preservation surgery (20%), and total knee arthroplasty (23%).

CONCLUSION

Nearly half of patients presented at late stage compromising the potential for joint preservation. The difference in age of referral by over a decade, based on etiology of SOK, suggests a strong provider-based referral or screening bias may be present. Hence, a multidisciplinary approach to earlier detection and referral may be a more effective strategy for preventing the progression of SOK.

What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?

Purpose

Core decompression (CD) of the femoral head is performed to preserve the hip in avascular necrosis (AVN). The outcome following this procedure differs based on the medical centre and the technique. Also, the time to total hip replacement (THR) and the percentage of patients subsequently undergoing a THR are controversial.

Methods

A systematic review was performed following PRISMA guidelines. The search included CENTRAL, MEDLINE, EMBASE, Scopus, AMED and Web of Science Core Collection databases. Studies reporting the outcome of CD for AVN were assessed. Studies using additional implants, vascularized grafts or any type of augmentation were excluded. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC) tool.

Trial registration

International prospective register of systematic reviews (PROSPERO) - CRD42018100596.

Results

A total of 49 studies describing 2540 hips were included. The mean weighted follow-up time was 75.1 months and the mean age at surgery was 39 years. Twenty-four of 37 studies reported improvement in all outcome scores, whilst 9/37 studies report only partial improvement post-operatively. Four studies (4/37) described poor clinical outcomes following intervention. Data was pooled from 20 studies, including 1134 hips with a weighted mean follow-up of 56 months. The percentage of hips undergoing THR averaged 38%. The time to THR had a weighted mean of 26 months after CD.

Conclusion

Pooled results from 1134 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 38% of patients underwent a total hip replacement at an average of 26 months following core decompression without augmentation.

Electronic supplementary material

The online version of this article (10.1007/s00264-020-04790-9) contains supplementary material, which is available to authorized users.

Diagnosis of Osteonecrosis of the Femoral Head: Too Little, Too Late, and Independent of Etiology

BACKGROUND

Joint preservation is more effective in early-stage osteonecrosis of the femoral head (ONFH); thus, prompt diagnosis when the femoral head is still salvageable is important. We report a 20-year retrospective study that summarizes age at presentation, etiology, and Association Research Circulation Osseous stage at diagnosis.

METHODS

Our database was reviewed to identify patients younger than 65 years of age who were diagnosed with atraumatic ONFH between 1998 and 2018. Demographic characteristics of patients were evaluated and categorized into different subgroups.

RESULTS

Four hundred thirteen patients were identified. At initial presentation, 23% were diagnosed with early-stage ONFH, while 77% were diagnosed with late-stage ONFH. Forty-nine percent had a history of corticosteroid use, of which 13% were diagnosed with hematologic malignancy and 8% were diagnosed with lupus. Ethanol abuse, idiopathic, sickle cell disease, and human immunodeficiency virus were present in 11%, 30%, 3%, and 3%, respectively. The mean age of patients with corticosteroid use (40 ± 14 years) was significantly younger than ethanol use (46 ± 11 years, P = .014) and idiopathic causes (48 ± 11 years, P < .001), but significantly older than sickle cell disease (32 ± 11 years, P = .031). There was no difference in the age of presentation for early-stage and late-stage ONFH by etiology.

CONCLUSION

Nearly 80% of the patients presented with late-stage ONFH. Hence, we have a narrow window of opportunity for hip preservation surgery before femoral head collapse. A multidisciplinary approach to improve screening awareness for early detection by focusing on the etiologic identification and patient education might reduce the incidence of hip arthroplasty in young patients.

Risk factors for radiological changes after bipolar hemiarthroplasty for osteonecrosis of the femoral head

OBJECTIVES

This study aimed to report the mid-term radiological outcomes of patients with bipolar hemiarthroplasty (BHA) for stage 3 osteonecrosis of the femoral head (ONFH), and to identify the risk factors for postoperative radiological changes.

METHODS

We retrospectively investigated 62 patients (38 men and 24 women; mean age, 50.1 years) aged <70 years who underwent primary BHA for Association Research Circulation Osseous stage 3 ONFH between 1998 and 2010. The mean follow-up period after BHA was 12.8 years. The following changes were assessed on follow-up radiographs: outer head migration, polyethylene wear, and femoral osteolysis. The association between demographic data and the development of postoperative radiological changes was evaluated.

RESULTS

Radiological changes were found in 20 hips (32.3%) at a mean of 8.1 years after BHA; of these, three hips (4.8%) underwent total hip arthroplasty conversion at a mean of 10.9 years after BHA. Both univariate and multivariate analysis revealed that younger age and female sex were independent risk factors for the development of postoperative radiological changes.

CONCLUSION

The current results suggest that the indication of BHA should be carefully determined in young or female patients with ONFH, even when the disease is in the early stage.

Incidence and Risk Factors of Osteonecrosis of Femoral Head in Multiple Myeloma Patients Undergoing Dexamethasone-Based Regimens

Objectives

To investigate the incidence and risk factors for osteonecrosis of femoral head (ONFH) in multiple myeloma (MM) patients undergoing dexamethasone-based regimens (DBRs).

Methods

A retrospective study was conducted in MM patients administered DBRs between December 2012 and April 2015. Demographic, clinical, and laboratory data were extracted to compare between two groups. Incidence of ONFH were calculated and risk factors identified by both univariate and multivariate analysis.

Results

The study group comprised 105 patients undergoing DBRs. Seven patients with ONFH after DBRs were classified as the ONFH group, and the other 98 patients without ONFH were included in the non-ONFH group. Incidence of ONFH was 6.7%. Median age of developing ONFH was 51 years (45-64), and the male to female ratio was 6 : 1. A total of 12 femoral heads were involved, including unilateral in 2 patients and bilateral in 5 patients. After the multivariate analysis, four risk factors were confirmed including male, younger age, cumulative dose of dexamethasone, and hyperlipidemia.

Conclusion

The overall incidence of ONFH in MM patients treated with DBRs is 6.7%, and 4 risk factors are confirmed including male, younger age, cumulative dose of dexamethasone, and hyperlipidemia in our study.

Osthole stimulates bone formation, drives vascularization and retards adipogenesis to alleviate alcohol-induced osteonecrosis of the femoral head

Characteristic pathological changes in osteonecrosis of the femoral head (ONFH) include reduced osteogenic differentiation of bone mesenchymal stem cells (BMSCs), impaired osseous circulation and increased intramedullary adipocytes deposition. Osthole is a bioactive derivative from coumarin with a wide range of pharmacotherapeutic effects. The aim of this study was to unveil the potential protective role of osthole in alcohol‐induced ONFH. In vitro, ethanol (50 mmol/L) remarkably decreased the proliferation and osteogenic differentiation of BMSCs and impaired the proliferation and tube formation capacity of human umbilical vein endothelial cell (HUVECs), whereas it substantially promoted the adipogenic differentiation of BMSCs. However, osthole could reverse the effects of ethanol on osteogenesis via modulating Wnt/β‐catenin pathway, stimulate vasculogenesis and counteract adipogenesis. In vivo, the protective role of osthole was confirmed in the well‐constructed rat model of ethanol‐induced ONFH, demonstrated by a cascade of radiographical and pathological investigations including micro‐CT scanning, haematoxylin‐eosin staining, TdT‐mediated dUTP nick end labelling, immunohistochemical staining and fluorochrome labelling. Taken together, for the first time, osthole was demonstrated to rescue the ethanol‐induced ONFH via promoting bone formation, driving vascularization and retarding adipogenesis.

Prognosis after autologous peripheral blood stem cell transplantation for osteonecrosis of the femoral head in the pre-collapse stage: a retrospective cohort study

OBJECTIVES

Autologous peripheral blood stem cell (auto-PBSC) transplantation is an effective therapeutic for the osteonecrosis of the femoral head (ONFH) but without prognosis estimation. This study mainly aimed to (1) determine whether auto-PBSC transplantation is a promising option, (2) assess the risk of hip-preservation failure, (3) achieve a predictive model of femoral head survival after the intervention, and (4) eventually identify clinical indications for auto-PBSC transplantation in future.

METHODS

After reviewing the in-patient database of the First Affiliated Hospital of Zhejiang Chinese Medicine University from June 2012 to June 2014, 37 eligible patients with Association Research Circulation Osseous stage I or II ONFH who were receiving intra-arterial infusion of auto-PBSCs were recruited. A case form was designed to retrieve relevant data. Hip-preservation failure was defined as the endpoint. All participants were stratified by the categorical risk of collapse, which was statistically tested through log-rank analysis. All significant factors were evaluated using Cox proportional hazards regression model, and a predictive nomogram plot was generated.

RESULTS

In total, 47 hips were followed up for 53.96 ± 21.09 months; the median survival time was 60.18 months. Among the predictors, body mass index (BMI; P = 0.0015) and Harris hip score (HHS; P < 0.0001) independently affected femoral head survival. Patients with BMI ≥ 24 kg/m² exhibited a 2.58 times higher risk of hip-preservation failure [95% confidence interval (CI), 1.32-5.45] than those with BMI < 24 kg/m², whereas those with HHS ≥ 70 exhibited a 0.19 times lower risk (95% CI, 0.09-0.38) than those with HHS < 70. Hazard ratios associated with age (P = 0.042), BMI (P = 0.012), HHS (P = 0.022), and necrotic volume (P = 0.000) were 1.038 (95% CI, 1.001-1.075), 1.379 (95% CI, 1.072-1.773), 0.961 (95% CI, 0.928-0.994), and 1.258 (95% CI, 1.120-1.412), respectively. A nomogram plot (score test P = 0.000; C-index = 0.8863) was available for the orthopedic doctor to predict hip survival probability.

CONCLUSIONS

The results suggest that intra-arterial infusion of auto-PBSCs prolongs femoral head survival. Age, BMI, HHS, and necrotic volume can influence the efficacy of this intervention. This study was approved by ethics committee of the trial center, number 2019-KL-075-01.

Comparison of Clinical Outcomes, Radiological Outcomes and Bone Remodeling Outcomes Between Proximal Coated Single-Wedge New Stem and Full Coated Dual-Wedge Classic Stem in 1-Stage Bilateral Total Hip Arthroplasty

Background

This retrospective study investigated the clinical outcomes, radiological outcomes, and bone remodeling patterns associated with a Medial/Lateral Taper (M/L Taper) stem and Link Classic Uncemented (LCU) stem in 1-stage bilateral total hip arthroplasty (THA).

Material/Methods

The results of 52 patients who underwent 1-stage bilateral THA with a M/L Taper stem on one side and an LCU stem on the other between January 2012 and February 2015 were retrospectively compared. Patients were clinically assessed by the Harris hip score (HHS), visual analogue score (VAS) and incidence of complications. Radiological indicators were measured. Periprosthetic bone remodeling was assessed via bone mineral density (BMD) measurements.

Results

The mean follow-up time was 5.2 years. At each follow-up, there was no difference in the HHS and VAS between the 2 groups. The neck-shaft angle, offset, vertical height of the rotational center and limb lengthening were lower in the M/L Taper group than in the LCU group (P<0.001). The Engh total score was lower in the LCU group (P=0.039). Significantly higher (P<0.001) BMDs were observed in the M/L Taper group in Gruen zones 1, 2, and 6. significantly lower (P<0.001) BMDs were observed in the M/L Taper group in Gruen zones 3 and 5.

Conclusions

Due to the increased postoperative neck-shaft angle, the full coated dual-wedge classic stem was prone to cause lower limb lengthening. The proximal coated single-wedge new stem patients were more likely to have an insufficient postoperative neck length. The new stem achieved load transfer and proximal fixation, leading to better proximal femoral bone preservation is more in line with human biomechanical characteristics.

What are the outcomes of core decompression in patients with avascular necrosis? Protocol for a systematic review

Background: Core decompression is a hip preserving surgical procedure that is used to treat avascular necrosis (AVN) of the femoral head. The eventual clinical and radiological outcome following this procedure is varied in literature. Also, the time to a total hip replacement (THR) from the index procedure and the percentage of patients subsequently undergoing a THR is controversial. Furthermore, there are multiple surgical methods along with multiple augmentation techniques and various classification and staging systems described. The purpose of this systematic review, therefore, is to analyse the outcomes following decompression only, excluding any augmentation techniques for non-traumatic AVN of the femoral head. Methods: This protocol is being developed in line with the PRISMA-P guidelines. The search strategy includes articles from Medline, Embase, Google Scholar, CINHAL and Cochrane library. The review and screening will be done by two independent reviewers. Review articles, editorials and correspondences will be excluded. Articles including patients with sickle cell disease and with core decompression where augmentation is used will be excluded. The risk of bias and quality of articles will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for the different study designs included. Discussion: This study will be a comprehensive review on all published articles having patients with AVN of the femoral head and undergoing core decompression surgery only. The systematic review will then define the outcomes of the core decompression surgery based on clinical and radiological outcomes. Each outcome will include the different stages within it and finally, the total mean time to THR will be calculated. This will then be followed by assessing the cumulative confidence in evidence from all the data collected using the GRADE tool.   Registration: This systematic review is registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number:  CRD42018100596.

S100 Calcium Binding Protein A9 Represses Angiogenic Activity and Aggravates Osteonecrosis of the Femoral Head

Ischemic damage aggravation of femoral head collapse is a prominent pathologic feature of osteonecrosis of the femoral head (ONFH). In this regard, S100 calcium binding protein A9 (S100A9) is known to deteriorate joint integrity, however, little is understood about which role S100A9 may play in ONFH. In this study, a proteomics analysis has revealed a decrease in the serum S100A9 level in patients with ONFH upon hyperbaric oxygen therapy. Serum S100A9 levels, along with serum vascular endothelial growth factor (VEGF), soluble vascular cell adhesion molecule-1 (sVCAM-1), interleukin-6 (IL-6), and tartrate-resistant acid phosphatase 5b levels were increased in patients with ONFH, whereas serum osteocalcin levels were decreased as compared to healthy controls. Serum S100A9 levels were increased with the Ficat and Arlet stages of ONFH and correlated with the patients with a history of being on glucocorticoid medication and alcohol consumption. Osteonecrotic tissue showed hypovasculature histopathology together with weak immunostaining for vessel marker CD31 and von Willrbrand factor (vWF) as compared to femoral head fracture specimens. Thrombosed vessels, fibrotic tissue, osteocytes, and inflammatory cells displayed strong S100A9 immunoreactivity in osteonecrotic lesion. In vitro, ONFH serum and S100A9 inhibited the tube formation of vessel endothelial cells and vessel outgrowth of rat aortic rings, whereas the antibody blockade of S100A9 improved angiogenic activities. Taken together, increased S100A9 levels are relevant to the development of ONFH. S100A9 appears to provoke avascular damage, ultimately accelerating femoral head deterioration through reducing angiogenesis. This study provides insight into the molecular mechanism underlying the development of ONFH. Here, analysis also highlights that serum S100A9 is a sensitive biochemical indicator of ONFH.