Core decompression isolated or combined with bone marrow-derived cell therapies for femoral head osteonecrosis

Fibroblast IRF7-mediated chondrocyte apoptosis affects the progression of collapse in steroid-induced osteonecrosis of the femoral head

PURPOSE

The objective of this study was to identify potential genes implicated in the "peri-collapse" synovium of osteonecrosis of the femoral head through coding gene sequencing and to further clarify their specific mechanisms via in vitro experiments.

METHODS

Steroid-induced osteonecrosis of the femoral head (SIONFH) (n = 3), femoral neck fracture (FNF) (n = 3), and hip osteoarthritis (HOA) (n = 3) Synovial tissue of the hip joint was collected in total hip arthroplasty. A cellular model of SIONFH constructed from rat synovial fibroblasts by lipopolysaccharide intervention. Lentiviral technology was used to construct a model for fibroblast knockout of the Irf7 gene. HE was used to compare the characteristics of synovial tissue damage, and immunofluorescence and immunohistochemistry were used to compare the expression levels of VIM, IRF7, and IFNα. PCR, WB, and IF were used to examine Irf7 knockdown efficiency, chondrocyte proliferation (Col2a1, Aggrecan, Sox9), cartilage matrix degradation (Mmp13), and apoptosis (Bcl2, Bax, and Caspase3) expression under co-culture conditions. Crystalline violet staining was used to observe the migration rate of fibroblasts, and flow cytometry was used to detect the apoptosis level of chondrocytes under co-culture conditions.

RESULTS

Transcriptome sequencing of synovial tissue and fibroblasts ultimately screened for six differential genes, HOOK1, RNPC3, KCNA3, CD48, IRF7, SAMD9. Compared to FNF and HOA, synovial inflammatory cell recruitment and synovial hyperplasia were more pronounced in SIONFH. IF and IHC confirmed high expression of IRF7 and IFNα in the synovium of SIONFH. PCR and WB results suggested that fibroblasts highly expressed Irf7, Hook1, Rnpc3, Kcna3, Cd48, Samd9, Il-6, and Tnfα after lipopolysaccharide intervention, and the expression levels of Il-6 and Tnfα were significantly reduced after knockdown of Irf7 (P < 0.001). In the co-culture system, fibroblasts intervened with lipopolysaccharide significantly promoted chondrocyte apoptosis, the rate of cartilage matrix degradation, while inhibiting the level of chondrocyte proliferation, and this result was significantly reversed in Irf7 knockout fibroblasts. This was supported by flow cytometry results.

CONCLUSIONS

IRF7, HOOK1, RNPC3, KCNA3, CD48, and SAMD9 as potential genes affecting the progression of SIONFH collapse. Irf7 mediates the fibroblast inflammatory response and affects the collapse process of SIONFH by influencing chondrocyte apoptosis. Thus, intervention in IRF7 holds promise as one of the key targets for reversing the collapse process of SIONFH.

Icariin promotes osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) by activating PI3K-AKT-UTX/EZH2 signaling in steroid-induced femoral head osteonecrosis

BACKGROUND

Differentiation of bone marrow mesenchymal stem cells (BMSCs) is pivotal in the pathogenesis of steroid-induced femoral head osteonecrosis. Icariin, an active ingredient in Epimedii herba, has the potential to regulate osteogenic differentiation of BMSCs. Nevertheless, the related mechanism is still unclear. The study aimed to explore whether icariin can affect osteogenic differentiation by activating PI3K/AKT signaling to alter UTX and EZH2 expression and thus regulating osteogenesis-related genes in BMSCs.

METHODS

BMSCs were collected from Sprague Dawley rats and identified by measuring the positive ratios of cell markers using flow cytometry. Cells were treated with 1 μmol/L dexamethasone (DEX) for 24 h with or without 0.1-10 μM of icariin treatment. Cell counting Kit-8 (CCK-8) assays and flow cytometry analyses were performed to measure cell viability and apoptosis. Western blotting was conducted for measurement of apoptotic markers, factors involved in the PI3K/AKT-UTX/EZH2 pathway, osteogenic markers, and adipogenesis-related factors. Alizarin red S staining and Oil-red O staining were performed to measure the effect of DEX, icariin, UTX overexpression, or EZH2 knockdown on osteogenic and adipogenic differentiation of BMSCs.

RESULTS

Icariin ameliorated DEX-induced rat BMSC injury. Icariin activated the PI3K/AKT signaling, thereby upregulating UTX and phosphorylated EZH2 levels while inhibiting EZH2 and H3K27me3 expression. Additionally, icariin promoted osteogenic differentiation and inhibited adipogenic differentiation of BMSCs. Importantly, overexpressing UTX or silencing EZH2 exerted similar effects on BMSC differentiation as icariin did.

CONCLUSIONS

Icariin promotes osteogenic differentiation of DEX-treated BMSCs by activating PI3K/AKT signaling to upregulate UTX and inhibit EZH2, finally inducing H3K27me3 depletion.

Relationship between anterior or posterior femoral head necrosis and collapse based on MRI-defined key necrotic layer sets

BACKGROUND

Current clinical studies on femoral head necrotic lesions primarily focus on the medial and lateral regions, while detailed MRI-based methods to evaluate the relationship between anterior or posterior necrosis and collapse remain lacking.

OBJECTIVE

By defining the anterior and posterior positions of the femoral head in MRI, a method was proposed for rapid clinical prognosis assessment of femoral head necrosis based on necrotic location.

METOHD

A retrospective analysis was conducted on TSE sequence T1W1 coronal plane images from 200 cases of femoral head necrosis. The frequency of necrotic lesions appearing on each MRI layer was statistically analyzed to construct a high-frequency necrotic layer set. Among these cases, 100 hips were randomly selected, and the relationship between femoral head collapse at one-year follow-up and different high-frequency necrotic layer sets was analyzed to identify the key necrotic layer set. Based on this, the anterior and posterior regions of the femoral head were defined on MRI. The remaining 100 hips were used as a validation set to assess the impact of anterior or posterior necrosis of the femoral head, as defined by this method, on collapse.

RESULTS

In this study, a total of eight high-frequency necrotic lesion layer sets (S1-S8) were constructed based on MRI data. Among them, S3 (L1 + L2 + L0 + L3) showed the strongest correlation with femoral head collapse, with an AUC of 0.662. Therefore, S3 was defined as the anterior side of the femoral head. Analysis of the validation set revealed that, using this method, the probability of femoral head collapse was 11.4 times higher when necrotic lesions appeared on the anterior side compared to the absence of necrosis on the anterior side.

CONCLUSION

In MRI, the anterior side of the femoral head corresponds to the S3 region, where necrosis increases the risk of collapse by 11.4 times.

Personalizing core decompression grafting technique for osteonecrosis of the femoral head: calculating the volume of bone resected and adjunct volume required to fill the defect

BACKGROUND

Osteonecrosis of the femoral head can be a debilitating disease leading to collapse of the femoral head and the subsequent need for a hip arthroplasty. Core decompression has emerged as a leading treatment to prevent collapse. Adjunctive therapies, such as bone graft, bone marrow aspirate concentrates, or synthetic bone substitutes are utilized to promote native bone regeneration. Determining the amount of bone resected and the volume of adjunct required is challenging, especially with newer minimally invasive reamers. Under- or over-filling the defect may impact progression of the disease or cause morbidity.

SURGICAL TECHNIQUE

We introduce a mathematical method to be utilized intraoperatively to calculate the volume of bone resected during core decompression with an expandable reamer. This method approximates the core decompression defect as two cylinders using measurements that can be easily taken during the procedure and can be adapted for use with any of the expandable reamer systems available. Using this technique, surgeons can calculate the size of the defect created, which can be used to personalize the amount of adjunct delivered to each patient.

CONCLUSIONS

When adjunctive therapies are used with core decompression to treat ONFH, care must be taken when filling the core decompression defect to avoid under- or over-filling the defect, potentially increasing the risk of complications or reducing the efficacy of the procedure. We provide a simple worksheet that can be used by surgeons to help determine how much adjunct should be used.

Study on the mechanism of Shuanghe decoction against steroid-induced osteonecrosis of the femoral head: insights from network pharmacology, metabolomics, and gut microbiota

BACKGROUND

Steroid-induced osteonecrosis of the femoral head (SONFH) is a challenging and debilitating orthopedic condition with a rising incidence in recent years. Shuanghe Decoction (SHD), a traditional Chinese medicine formula, has shown significant efficacy in treating SONFH, though its underlying mechanisms remain unclear.

PURPOSE

This study aims to elucidate the therapeutic effects and potential mechanisms of SHD on SONFH through in vivo experiments, combined with network pharmacology, metabolomics, and gut microbiota analysis.

MATERIALS AND METHODS

Forty male Sprague-Dawley rats (300 ± 20 g) were randomly assigned to four groups: Control, Model, SHD-L, and SHD-H, with 10 rats each. SONFH was induced in all groups except the Control group using lipopolysaccharide and methylprednisolone. The SHD-L and SHD-H groups were treated with Shuanghe decoction at doses of 4.86 g/kg/day and 9.72 g/kg/day, respectively, for eight weeks. Bone morphology, pathological changes, and osteogenic factors were evaluated using Micro-CT, histological staining, and immunohistochemistry. Network pharmacology, metabolomics, and gut microbiota analyses were conducted to explore SHD's mechanisms.

RESULTS

SHD improved bone morphology and increased osteogenic factor expression (RUNX2, OCN, COL-I). Network pharmacology indicated that metabolic pathways play a key role in SHD's therapeutic effects. Metabolomic analysis identified 14 differential metabolites, including 21-hydroxypregnenolone and tyramine, which were restored to normal levels by SHD. Gut microbiota analysis revealed that SHD modulated bacterial abundance, particularly Verrucomicrobia, Allobaculum, and Burkholderiales. A comprehensive network identified two key metabolites (tyramine, 21-hydroxypregnenolone), seven targets (CYP19A1, CYP1A2, CYP1B1, CYP2C9, CYP3A4, MIF, and HSD11B1), two metabolic pathways (tyrosine metabolism, steroid hormone biosynthesis), and four bacterial taxa (Jeotgalicoccus, Clostridium, Corynebacterium, rc4-4) as central to SHD against SONFH.

CONCLUSION

SHD alleviates SONFH by reshaping gut microbiota, reversing metabolic imbalances, and enhancing osteogenesis. Our findings provide novel insights into the pharmacological mechanisms of SHD, laying a foundation for its clinical application in treating SONFH.

Jack Surgery: Reconstructing Collapsed Femoral Head in Association Research Circulation Osseous Stage III Osteonecrosis: A Series of 13 Cases

OBJECTIVE

According to Association Research Circulation Osseous (ARCO) staging, patients with ARCO III osteonecrosis of femoral head (ONFH) have joint pain and dysfunction due to the collapse of femoral head. Current hip preservation surgeries are not satisfying in the treatment of ARCO III ONFH according to the long-term follow-up. In our practice, we focused on reconstructing femoral head by restoring the round shape of femoral head and subsequently preventing the development of hip arthritis. To lift the collapsed femoral head and postpone the potential total hip arthroplasty, we practiced Jack surgery, combining surgical hip dislocation, removal of necrotic bone, impaction bone grafting, and lifting the cartilage of femoral head.

METHODS

From February 2019 to July 2022, 13 patients (15 hips) who received Jack surgery in the research center were included in this retrospective study. Follow-up was conducted every 3 months after surgery for imaging and clinical evaluation. The differences between visual analogue scale (VAS) and Harris hip score (HSS) before and after surgery were compared to observe whether the femoral head collapsed and whether osteotomy healed after surgery. Severe collapse of the femoral head ( > 2 mm) or receiving total hip arthroplasty (THA) was defined as failure of hip preservation therapy. An Independent sample t-test was used to compare the data, and the chi-square test was used for categorical data.

RESULTS

All the 13 patients successfully completed the surgery and were followed up. The average time of follow-up was 36.46 ± 16.87 months (ranging from 14 to 66 months). HSS was assessed 12 months after surgery: excellent in 1 patient with 1 hip; good in 9 patients with 11 hips; modest in 3 patients with 3 hips. To the last follow-up, the VAS scores decreased from 6.17 ± 1.02 to 2.08 ± 0.90 (p < 0.001), HSS increased from 46.69 ± 4.15 to 89.77 ± 2.86 (p < 0.001). No deep infection, fracture, osteotomy nonunion, nerve injury, deep vein thrombosis, pulmonary embolism, or other complications occurred.

CONCLUSION

For young patients with ONFH of ACRO III, this surgical technique can effectively restore the original shape of the femoral head and achieve satisfactory hip function in the short term. The mechanism is similar to jacking the roof of a house; thus, we named it "Jack surgery".

Association of serum and local GRP78 and CHOP expressions with disease progression in patients with non-traumatic osteonecrosis of femoral head

BACKGROUND

The endoplasmic reticulum stress (ER stress) has been involved in various musculoskeletal disorders including non-traumatic osteonecrosis of femoral head (NT-ONFH).

OBJECTIVE

The current study aimed to investigate the association of glucose-regulated protein 78 (GRP78) as well as CCAAT/enhancer-binding protein homologous protein (CHOP) expressions in serum and femoral head (FH) tissues with NT-ONFH's severity.

METHODS

We enrolled NT-ONFH patients (n = 150) alongside healthy controls (HCs, n = 150). Meanwhile, 49 patients with femoral neck fracture (FNF) were also enrolled. Serum CHOP and GRP78 levels were determined through enzyme linked immunosorbent assay (ELISA). Local CHOP and GRP78 expressions were detected by immunohistochemistry, western blot, alongside real-time polymerase chain reaction (RT-PCR). Radiographic severity was assessed by FICAT grading system. The visual analogue scale (VAS) together with Harris hip score (HHS) were utilized to determine symptomatic severity.

RESULTS

Serum CHOP and GRP78 levels were markedly increased in NT-ONFH patients than HCs. NT-ONFH patients at FICAT stage 4 showed significant higher serum CHOP and GRP78 levels in contrast with those at stage 3. Furthermore, patients at stage 3 demonstrated higher serum CHOP and GRP78 levels than those at stage 2. There was a positive correlation observed between the serum CHOP and GRP78 levels and the severity of the FICAT stages. A total of 42 ONFH patients at FICAT stage 3, 40 patients at FICAT stage 4, and 49 FNF patients received total hip replacement (THR). The mRNA and protein levels of CHOP and GRP78 were elevated in necrotic area compared to the non-necrotic area of ONFH patients and the FH tissues of FNF patients with statistical significance. The expression levels of CHOP and GRP78 within the local tissues were significantly elevated in patients at FICAT stage 4 as opposed to those at stage 3. Besides, ROC curve analysis indicated that serum and local CHOP and GRP78 expressions may act as indicators of disease progression. The levels of CHOP and GRP78, both in serum and at the local site, were in a positive correlation with VAS scores but an inverse relationship with HHS.

CONCLUSIONS

Serum and local GRP78 as well as CHOP expressions were positively linked with disease progression in NT-ONFH patients. Potential therapeutics targeting ER stress related protein may serve as a method for alleviating NT-ONFH.

Exosomal miR-122 derived from M2 macrophages induces osteogenic differentiation of bone marrow mesenchymal stem cells in the treatment of alcoholic osteonecrosis of the femoral head

Alcoholic osteonecrosis of the femoral head (AIONFH) is caused by long-term heavy drinking, which leads to abnormal alcohol and lipid metabolism, resulting in femoral head tissue damage, and then pathological necrosis of femoral head tissue. If not treated in time in clinical practice, it will seriously affect the quality of life of patients and even require hip replacement to treat alcoholic femoral head necrosis. This study will confirm whether M2 macrophage exosome (M2-Exo) miR-122 mediates alcohol-induced BMSCs osteogenic differentiation, ultimately leading to the inhibition of femoral head necrosis. M2 macrophages were identified by flow cytometry, and the isolated exosomes were characterized by transmission electron microscopy (TEM) and Nanoparticle Tracking Analysis (NTA). Next, miR-122 was overexpressed by transfecting miR-122 mimic, and the expression of miR-122 in M2 macrophages and their exosomes was evaluated. Subsequently, the effect of exosomal miR-122 on the osteogenic differentiation ability of BMSCs was detected, including cell proliferation, expression of osteogenic-related genes (RUNX2, BMP2, OPN, ALP), and calcium nodule formation. Finally, the therapeutic effect of M2-Exo was analyzed in a rat model of AIONFH, and bone repair and pathological damage were evaluated by Micro-CT, RT-qPCR, HE, Masson staining, and immunohistochemistry (COL I). The results showed that M2 macrophages were successfully polarized, with an average M2-Exo particle size of 156.4 nm and a concentration of 3.2E + 12 particles/mL. The expression of miR-122 in M2 macrophages is significantly higher than that in M0 macrophages, and miR-122 mimic can increase the content of miR-122 in M2-Exo. miR-122 in M2-Exo can promote osteogenic differentiation of rat bone marrow BMSCs, enhance cell viability, and increase the expression of osteogenesis-related genes. After being applied to the AIONFH rat model, the injection of M2-exo and miR-122 mimics significantly improved the repair effect of articular cartilage, alleviated pathological changes, and promoted the regeneration of bone tissue. M2-macrophage-derived exosomal miR-122 induces osteogenic differentiation of bone mesenchymal stem cells in treating AIONFH.

Healing beyond bone: a qualitative study of the core decompression experience of physically active patients with stage II hip avascular necrosis

BACKGROUND

Avascular necrosis (AVN) of the femoral head is a degenerative condition characterized by ischemic bone death, resulting in pain and impaired mobility. Core decompression, a surgical intervention, is widely performed for stage II AVN to alleviate symptoms and delay disease progression. While clinical and radiological outcomes are well-documented, the psychosocial dimensions of recovery remain underexplored. This study aims to understand the experiences of physically active patients diagnosed with stage II AVN who have undergone core decompression surgery during their follow-up period, allowing for a broader evaluation of the experiences of this patient group.

METHODS

This study used semi-structured interviews, in-depth follow-up questions, and thematic analysis to explore the experiences of physically active patients who underwent core decompression surgery for stage II AVN of the femoral head. The participants were assessed 1-3 years post-surgery. Conducted in the Orthopaedics and Traumatology outpatient clinic of Adana City Training and Research Hospital, the study included 31 patients who had core decompression surgery between January 2020 and January 2024, with at least one year of follow-up data. Data collection, including demographic and qualitative information, was carried out during the first week of April 2024, followed by the member-checking process in the third week. A thematic analysis checklist and COREQ guidelines were used to ensure analysis reliability.

RESULTS

The experiences of 31 patients (mean age 37.19 ± 8.21 years, 12 females, 19 males) were summarized into five main themes that emerged from the data analysis process: 'Expectations and Concerns Before Surgery,' 'Postoperative Physical Experiences,' 'The Psychological and Emotional Process,' 'Social Support and Family Relationships,' and 'Health Services and Medical Support.'' Twelve sub-themes emerged from the main themes.

CONCLUSIONS

Core decompression offers significant benefits to patients with stage II AVN by improving mobility and reducing pain. However, psychological support, patient education, and robust social networks are essential to address the holistic needs of recovery. These findings highlight the importance of integrating patient-centered approaches into surgical care to optimize outcomes and satisfaction. Further qualitative research is needed to explore the experiences of AVN patients at different stages to inform multidisciplinary care strategies.

Location or size? A finite element analysis study of necrotic lesion impact on femoral head collapse

BACKGROUND

The location and size of necrotic lesions are important factors for collapse, The preserved angles (PAs) are divided into anterior preserved angle (APA) and lateral preserved angle (LPA), which could accurately measure the location of necrosis lesion. We used them to evaluate the effect of the location and size of necrotic lesions on collapse by finite element analysis, to offer a framework for evaluating the prognosis of osteonecrosis of the femoral head (ONFH) in clinical settings.

METHODS

3 left hip models were constructed based on CT data. Within each hip model, three necrosis lesion models were modeled, with necrotic tissue volumes of 30%, 50%, and 70% repectively. The ONFH models with LPA of 45.5°, 50.5°, 55.5°, 60.5°, 65.5°, 70.5°, and 75.5° when APA was 60.5°, and ONFH models with APAs of 45.5°, 50.5°, 55.5°, 60.5°, 65.5°, 70.5°, and 75.5° when LPA was 60.5° were Constructed. The maximum von Mises stess of the femoral head and necrotic lesion, as well as the femoral head displacement, were calculated to evaluate the biomechanical effects of these models.

RESULTS

(1) In models with the same necrotic volume, when APA was 60.5°, the indexes of the LPA < 60.5° models were significantly higher than those of the LPA ≥ 60.5° models (P < 0.05); the differences of the indexes among the LPA ≥ 60.5° models were not statistically significant (P > 0.05). (2) When LPA was 60.5°, the indexes of models with APA < 60.5 ° and APA ≥ 60.5 ° show the same trend as the former. (3) In the models with the same PAs, there was no statistically significant difference in the indexes (P > 0.05).

CONCLUSION

The location of the necrotic lesion exerts a greater impact on femoral head collapse compared with the size of the lesion. The location of the necrosis may deserve more consideration when assessing the risk of collapse in patients with early onset ONFH.

Integrated bioinformatics analysis and experimental validation of exosome-related gene signature in steroid-induced osteonecrosis of the femoral head

BACKGROUND

Steroid-induced osteonecrosis of the femoral head (SIONFH) is a universal hip articular disease and is very hard to perceive at an early stage. The understanding of the pathogenesis of SIONFH is still limited, and the identification of efficient diagnostic biomarkers is insufficient. This research aims to recognize and validate the latent exosome-related molecular signature in SIONFH diagnosis by employing bioinformatics to investigate exosome-related mechanisms in SIONFH.

METHOD

The GSE123568 and GSE74089 datasets were employed to conduct differentially expressed genes (DEGs) analysis, and the GSE123568 dataset was subjected to perform weighted genes co-expression network analysis (WGCNA). The exosome-related genes (ERGs) were retrieved from the GeneCards database. We identified differentially expressed exosome-related genes (DEERGs) between healthy controls (HC) and SIONFH patients, and a consensus clustering analysis was then implemented to group the SIONFH patients. The CIBERSORT was implemented to calculate the immune cell infiltration. Gene Set Variation Analysis (GSVA), Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) were conducted to investigate latent enriched pathways. In addition, machine-learning algorithms were applied to refine the DEERGs. Ultimately, we verified the diagnostic significance and expression of the hub genes using the SIONFH datasets and performing quantitative reverse transcription polymerase chain reaction (qRT-PCR) analysis.

RESULTS

This study identified twenty DEERGs from the peripheral serum and hip articular cartilage samples of SIONFH patients and HC. Two SIONFH subtypes related to ERGs were identified, and distinctions in pathways and immune cell infiltration patterns were compared. SIONFH's high-risk subpopulation exhibited enriched immune-related pathways and high immune cell infiltration, such as M0 macrophages, resting mast cells, and neutrophils. Three machine-learning algorithms then determined LCP1, PNP, UBE2V1, and ZFP36 as four exosome-related hub genes (ERHGs). Compared to HC samples, these ERHGs showed excellent diagnostic efficiency (overall AUC for ERHGs is in the range of 0.923 to 0.970 in GSE123568) in SIONFH samples. LCP1, PNP, UBE2V1, and ZFP36 expressions were validated in the GSE123568 and GSE74089 datasets and finally detected in peripheral serum samples with accordant expression by RT-qPCR.

CONCLUSION

Twenty potential exosome-related genes involved in SIONFH were identified through bioinformatics analysis. LCP1, PNP, UBE2V1, and ZFP36 might become candidate biomarkers and therapeutic targets because they have an intimate relationship with exosomes. These findings shed light on the exosome-related acquaintance of SIONFH and might contribute to the diagnosis and prognosis of SIONFH.

Aiding Diagnosis and Classifying of Early Stage Osteonecrosis of the Femoral Head with Convolutional Neural Network Based on Magnetic Resonance Imaging

Introduction

The Steinberg classification system is commonly used by orthopedic surgeons to stage the severity of patients with osteonecrosis of the femoral head (ONFH), and it includes mild, moderate, and severe grading of each stage based on the area of the femoral head affected. However, clinicians mostly grade approximately by visual assessment or not at all. To accurately distinguish the mild, moderate, or severe grade of early stage ONFH, we propose a convolutional neural network (CNN) based on magnetic resonance imaging (MRI) of the hip joint of patients to accurately grade and aid diagnosis of ONFH.

Materials and Methods

T1-MRI images of patients diagnosed with early stage ONFH were collected. Three orthopedic surgeons selected 261 slices containing images of the femoral head and labeled each case with the femoral head necrosis classification. Our CNN model learned, trained, and segmented the regions of femoral head necrosis in all the data.

Results

The accuracy of the proposed CNN for femoral head segmentation is 97.73%, sensitivity is 91.17%, specificity is 99.40%, and positive predictive value is 96.98%. The diagnostic accuracy of the overall framework is 90.80%.

Conclusions

Our proposed CNN model can effectively segment the region where the femoral head is in MRI and can identify the region of early stage femoral head necrosis for the purpose of aiding diagnosis.

Global incidence of osteonecrosis of the femoral head after femoral neck fracture surgery in adolescents: a meta-analysis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a significant postoperative complication following femoral neck fractures (FNFs) in adolescents, that has garnered considerable attention from researchers. Despite this interest, the incidence of ONFH in adolescents post-FNF surgery has not been extensively evaluated. To contribute to the body of research, we performed a meta-analysis utilizing articles sourced from multiple databases, with an emphasis on the rate of ONFH occurrence in young adolescents following FNF surgery.

OBJECTIVE

The purpose of this study was to investigate the incidence of ONFH after FNFs in adolescents worldwide and analyse potential risk factors affecting its occurrence to provide guidance for the treatment and rehabilitation after FNFs in adolescents and reduce the incidence of ONFH.

METHODS

A comprehensive search of medical literature databases, including MEDLINE, Web of Science, the Cochrane Library, and Embase, was conducted to identify relevant studies on ONFH and its associated risk factors after surgical treatment for FNFs in adolescents, covering the period from the establishment of the database to April 2024. Studies that did not meet the inclusion criteria were excluded. The study was conducted based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Literature extraction, management, and data entry were performed using Zotero 6.0 and Excel 2016. The meta-analysis was conducted using R Studio 4.2.2. Subgroup analysis, sensitivity analysis, and assessment of publication bias were performed to explore sources of heterogeneity and evaluate the reliability of the results. This study has been registered on Prospero. (registration number: CRD4202452794; date of registration: 03/04/2024) RESULTS: A total of 17 publications involving 862 patients with FNFs were included in this meta-analysis. The findings revealed that the incidence of ONFH after FNF surgery in adolescents was 24.02% [95% CI (0.2118, 0.2712)]. The included studies demonstrated good consistency, and no publication bias was observed.

CONCLUSION

This study revealed that the incidence of ONFH after FNFs in adolescents is high (24.02%). Early screening and effective treatment of postoperative patients are crucial.

ERAS perioperative management measures in total hip replacement in HIV-positive patients with osteonecrosis of the femoral head

OBJECTIVE

This study aims to investigate the feasibility and effectiveness of enhanced recovery after surgery (ERAS) in HIV-positive patients diagnosed with osteonecrosis of the femoral head (ONFH) undergoing total hip replacement (THR).

METHODS

We retrospectively included 80 HIV-positive patients diagnosed with ONFH who underwent THR between 2011 and 2022. Forty patients treated before August 2019 constituted the control group, receiving standard antiviral regimens and traditional perioperative management pathways. The remaining 40 patients, treated after August 2019, formed the study group, which followed the ERAS protocol. This protocol emphasized the use of more effective antiviral medications, rapid viral load reduction, immune enhancement, improved nutritional status, control of co-infections, prophylactic antibiotics, and anti-osteoporosis measures. We recorded patients' general status and imaging examinations before surgery, as well as detailed perioperative management strategies, antiviral regimens, durations, and immunological indicators for both groups. Targeted and standardized treatment measures were applied to the ERAS group, allowing for a comparison of the efficacy of perioperative management between the two patient groups.

RESULTS

Preoperative nutritional and immune indicators were lower in the control group than in the study group, while inflammatory markers were higher. Postoperatively, immune, nutritional, and inflammatory indicators were significantly better in the ERAS group compared to the control group. Following antiviral treatment, the viral load was predominantly undetectable in the ERAS group (target not detected, TND). Comprehensive measures minimized complications in the ERAS group (P = 0.028, P < 0.05). The hospitalization duration for the ERAS group was significantly shorter than that of the control group, with both groups showing marked improvement compared to preoperative conditions and no incidents of loosening or dislocation.

CONCLUSION

Strengthening antiviral treatment, anti-infective strategies, incision care, and nutritional support effectively prevents and reduces complications such as delayed wound healing in HIV-positive patients. The implementation of ERAS measures requires careful attention to the patient's immune status, close monitoring of clinical changes, and timely adjustments to treatment and care plans.

LEVEL OF EVIDENCE

Treatment studies.

A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a progressive and debilitating condition characterized by the death of bone tissue due to inadequate blood supply. Despite advances in diagnostic imaging and treatment strategies, predicting the risk of femoral head collapse remains a significant clinical challenge. This study seeks to address this gap by developing a robust prognostic model that integrates clinical, imaging, and laboratory data to improve early diagnosis and guide therapeutic decision-making.

METHODS

We conducted a qualitative systematic review and employed the Delphi method to select key prognostic factors from clinical data, imaging findings, and laboratory indicators. The study included ONFH patients treated from January 2014 to December 2021. We used univariate and multivariate Cox regression analyses to develop a nomogram for predicting the risk of femoral head collapse. The model's performance was evaluated using the concordance index (C-index), calibration plots, and decision curve analysis (DCA).

RESULTS

The study included 297 patients (454 hips) with ONFH. Key prognostic factors identified included pain presence (p < 0.001, RR = 0.185, 95% CI: 0.11-0.31), JIC classification (C1: p < 0.001, RR = 0.096, 95% CI: 0.054-0.171; C2: p < 0.001, RR = 0.323, 95% CI: 0.215-0.487), necrotic area (3 < MNAI < 6: p < 0.001, RR = 0.107, 95% CI: 0.061-0.190; MNAI ≥ 6: p < 0.001, RR = 0.466, 95% CI: 0.314-0.692), weight-bearing reduction (p < 0.001, RR = 0.466, 95% CI: 0.323-0.672), preservation of the anterolateral pillar (p < 0.001, RR = 0.223, 95% CI: 0.223-0.473), and subchondral bone fracture on CT (p < 0.001, RR = 0.32, 95% CI: 0.217-0.472). The nomogram demonstrated a high C-index of 0.88, indicating excellent predictive accuracy. Calibration plots showed good agreement between predicted and observed outcomes, and DCA confirmed the model's clinical utility.

CONCLUSIONS

The prognostic model developed in this study provides a reliable tool for predicting femoral head collapse in ONFH patients. It allows for early identification of high-risk patients, guiding personalized treatment strategies to improve patient outcomes and reduce the need for invasive surgical procedures.

Arthroscopic assisted versus open core decompression for osteonecrosis of the femoral head: A systematic review and meta-analysis

BACKGROUND

Minimally invasive treatment options for osteonecrosis of the femoral head (ONFH) have been a prominent area of research in recent years. Arthroscopic-assisted treatments have been applied in the clinical management of ONFH; however, high-quality evidence verifying their effectiveness and safety is still lacking.

OBJECTIVE

To systematically assess the clinical efficacy and safety of arthroscopic-assisted core decompression (AACD) in treating ONFH.

METHODS

A comprehensive literature search was conducted in PubMed, Web of Science, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, China Science and Technology Journal Database, WanFang, and the Chinese BioMedical Literature Database, from inception to June 25, 2024. We identified randomized controlled trials and non-randomized controlled studies on AACD for the treatment of ONFH based on predefined inclusion and exclusion criteria. A meta-analysis was performed using Review Manager 5.4.1 and Stata 17.0 software. The analyzed outcomes included operative time, intraoperative blood loss, length of hospital stay, postoperative femoral head collapse rate, Harris hip score, and postoperative complication rate. The Grades of Recommendations, Assessment, Development, and Evaluations (GRADE) system was used to assess the quality of evidence for the outcome indicators.

RESULTS

A total of fourteen studies were included in this meta-analysis, comprising 1,063 patients-541 in the core decompression (CD) group and 522 in the AACD group. The meta-analysis revealed no significant differences between the two groups in terms of intraoperative blood loss, length of hospital stay, 12-month postoperative Harris hip score, or overall postoperative complication rate (P > 0.05). However, the AACD group had a longer operative time (MD = 31.19, 95% Cl: 5.32 to 57.07, P = 0.02) and a lower overall postoperative femoral head collapse rate (RR = 0.49, 95% Cl: 0.27 to 0.89, P = 0.02) compared with the CD group. Additionally, the AACD group showed significant improvements in Harris hip scores at 3 months (MD = 6.39, 95% Cl: 5.44 to 7.33, P < 0.00001), 6 months (MD = 7.56, 95% Cl: 6.63 to 8.49, P < 0.00001), ≥ 24 months (MD = 7.00, 95% Cl: 4.80 to 9.21, P < 0.00001), and at the last follow-up (MD = 6.89, 95% Cl: 5.30 to 8.48, P < 0.00001) compared to the CD group. The GRADE evidence assessment indicated that the overall postoperative complication rate was supported by moderate-quality evidence, while the evidence for operative time, intraoperative blood loss, postoperative femoral head collapse rate, and Harris hip score was of low quality. The evidence for length of hospital stay was deemed very low quality.

CONCLUSION

This meta-analysis suggests that AACD is an effective and safe treatment for patients with ONFH. However, due to the limited quantity and quality of the included studies, these results should be interpreted with caution. Further high-quality studies are recommended to confirm these findings.

Predicting steroid-induced osteonecrosis of the femoral head: role of lipid metabolism biomarkers and radiomics in young and middle-aged adults

BACKGROUND

Femoral head necrosis is a common orthopedic disease that results in significant physical disability in patients. Early prediction and diagnosis of steroid-induced osteonecrosis of the femoral head (SONFH) are crucial for the prevention and treatment of this condition.

METHODS

In this study, initial CT images and clinical data of patients with SONFH, admitted from January 2019 to December 2022, were collected. Patients were grouped as follows: (1) those diagnosed with SONFH at the initial diagnosis (control group), and (2) those with high-risk factors but no symptoms at first diagnosis, who developed SONFH two years later (experimental group). CT imaging histological features, clinical characteristics, and transcriptome screening for differentially expressed genes, pathway enrichment, and immune infiltration analyses were performed.

RESULTS

Significant differences were found in triglyceride (TG) levels between the training and validation groups. Age, sex, alkaline phosphatase (ALP), and hemoglobin levels differed between the training and internal validation groups, while HDL and red blood cell counts varied between the training and external validation groups. Univariate analysis showed that age, TG, HDL, and Radiomics scores influenced SONFH, while multivariate analysis revealed TG, HDL, and Radiomics scores were closely related to SONFH. Transcriptomic analysis showed associations with sphingolipid and adipocyte signaling pathways, along with immune cell involvement, linking SONFH to lipid metabolism and atherosclerosis.

CONCLUSIONS

These findings indicate a significant association between steroid-induced osteonecrosis of the femoral head and age, with TG and HDL serving as indicators of lipid metabolism closely correlated with the occurrence of SONFH. Radiomics scores were also found to correlate with SONFH occurrence, supported by transcriptomic and CT imaging findings. However, this study has limitations, including its retrospective design and a relatively limited sample size, which may impact the generalizability of the results. Further prospective studies with larger, more diverse populations are needed to validate and enhance the predictive model.

Preliminary study of the role of histone deacetylase (HDAC) in steroid-induced avascular necrosis of the femoral head induced by BMSC adipogenic differentiation

Our previous research revealed a close association between the acetylation of peroxisome proliferator-activated receptor γ (PPARγ) histone H3K27 and the adipogenic differentiation of bone marrow mesenchymal stem cells (BMSCs). We preliminarily explored the epigenetic mechanism of steroid-induced avascular necrosis of the femoral head (SANFH) development, but the specific histone deacetylase (HDAC) involved in this regulatory process remains unknown. In this study, we combined cell, animal, and clinical specimen experiments to screen for specific HDAC genes that could regulate BMSC adipogenic differentiation and to explore their roles. The results showed that dexamethasone (DEX) significantly exacerbated the imbalance between the adipogenic and osteogenic differentiation of BMSCs, and there were differences in HDAC expression in the adipogenic differentiation cell models, with histone deacetylase 10 (HDAC10) showing the most significant decrease in expression. Subsequent use of a chromatin immunoprecipitation assay kit and quantitative polymerase chain reaction (ChIP‒qPCR) revealed a decrease in HDAC10 expression at predicted potential sites within the PPARγ promoter, indicating a significant decrease in HDAC10 enrichment in the PPARγ promoter region of BMSCs, thereby promoting sustained PPARγ expression. Additionally, immunohistochemistry of samples collected from mice and humans with SANFH and normal femoral heads revealed an imbalance between adipogenic and osteogenic differentiation in the necrotic area of femoral heads, with a significant decrease in the relative expression of HDAC10 in the necrotic area of femoral heads with SANFH. In summary, we speculate that HDAC10 affects the progression of SANFH by regulating BMSC adipogenic differentiation, a process possibly related to PPARγ histone acetylation. These findings provide a promising direction for the treatment of SANFH.

Three-dimensional mapping of necrotic lesions for early-stage osteonecrosis of the femoral head

BACKGROUND

There is a scarcity of evidence regarding the potential relationship between the size and location of necrotic lesions, which must be understood to provide optimal joint-preserving treatment. The purpose of this study was to characterize the distribution patterns of necrotic lesions of varying sizes in early-stage osteonecrosis of femoral head (ONFH) with the use of three-dimensional mapping.

METHODS

We retrospectively evaluated clinical CT images of the hips that were performed in the Third Hospital of Hebei Medical University from January 2018 to December 2022 and collected all CT images diagnosed with stage I and II ONFH. Three-dimensional structures that included both necrotic lesions and normal areas of the femoral heads were reconstructed and divided into eight regions to record their size and location. CT images for all lesions were superimposed onto a standard template, and three-dimensional mapping was created to determine the presence of concentrated areas of lesions.

RESULTS

In a cohort of 143 patients with stage I and II ONFH, a total of 150 hips were reviewed. For lesions with less than 15% of the femoral head volume, necrotic lesions predominantly involve regions I, III, and V, with region I showing concentration. For lesions with volumes ranging from 15 to 30%, necrotic lesions exhibited a wider distribution across regions I, II, III, IV, V, and VII, with significant concentrations in regions I, III, and V. For lesions exceeding 30% of the femoral head volume, the necrotic lesions were extensively distributed across nearly the entire femoral head, with a notable expansion of the concentrated necrotic areas.

CONCLUSIONS

The distribution of necrotic lesions varies with lesion size, with smaller lesions primarily concentrated in the anterior and medial regions of the femoral head, particularly in the anterosuperior region, while larger lesions expand to the lateral and inferior regions. These findings enhance existing classification systems and provide crucial insights for guiding hip-preserving surgical planning and approaches.

Loss of walking independence one year after primary total hip arthroplasty for osteonecrosis of the femoral head: incidence and risk prediction model

BACKGROUND

Assessment of postoperative ambulation in osteonecrosis of the femoral head (ONFH) patients treated with total hip arthroplasty (THA) is limited. This study aimed to define the incidence and risk factors for losing walking independence (LWI) at one-year postoperatively in patients with ONFH undergoing primary THA, and to establish and validate a predictive nomogram.

METHODS

This was a retrospective analysis of prospective collected data from patients admitted to a tertiary referral hospital with ONFH who underwent primary unilateral THA from October 2014 to March 2018. The Functional Independence Measure-Locomotion scale was used to quantify walking independence and was documented at a one-year continuous postoperative follow-up, which classified patients with a final score below 6 as LWI. Multivariate logistic regression identified independent risk factors for LWI, and a predictive nomogram was constructed based on the analysis results. The stability of the model was assessed using patients from April 2018 to April 2019 as an external validation set.

RESULTS

1152 patients were enrolled in the study, of which 810 were used in the training cohort and the other 342 for the validation cohort. The incidence of LWI was 5.93%. Multivariate analysis revealed that age 62 years or older (odd ratio (OR) = 2.37, 95% confidence interval (CI) 1.07-5.24), Charlson's comorbidity index 3 or higher (OR = 3.64, 95% CI 1.09-12.14), Association Research Circulation Osseous stage IV (OR = 2.16, 95% CI 1.03-4.54), reduced femoral offset (OR = 2.41, 95% CI 1.16-5.03), and a higher controlling nutritional status score (OR = 1.14, 95% CI 1.01-1.30) were independent risk factors of LWI. The nomogram had a concordance index of 0.773 and a Brier score of 0.049 in the training set, with corrected values of 0.747 and 0.051 after internal validation. The receiver-operating characteristic curve, calibration curve, Hosmer-Lemeshow test, and decision curve analysis all performed well in both the training and validation cohorts.

CONCLUSIONS

This study reported a 5.93% incidence of LWI and established a risk prediction model in patients undergoing THA for ONFH, supporting targeted screening and intervention to assist surgeons in assessing ambulation capacity and managing rehabilitation.

Surgical hip dislocation technique through the femoral head fovea fenestration and impaction bone grafting for the treatment of non-traumatic osteonecrosis of the femoral head: a retrospective study

BACKGROUND

Osteonecrosis of the femoral head (ONFH) often leads to the collapse of the femoral head, ultimately resulting in patients undergoing premature total hip arthroplasty (THA). The surgical hip dislocation (SHD) technique is a type of hip-preserving surgery aimed at delaying or avoiding THA. This study aims to evaluate the clinical efficacy of SHD techniques through femoral head fovea fenestration and impaction bone grafting for the treatment of non-traumatic ONFH.

METHODS

A retrospective analysis was conducted on the clinical data of 39 patients (39 hips) with non-traumatic ONFH who underwent SHD for treatment from 2016 to 2017. The Harris hip score (HHS) and the minimum clinically important difference (MCID) are used to evaluate clinical outcomes, while radiographic evaluations are conducted using X-rays. Kaplan-Meier survival analysis defined clinical failure as further THA, and conducted univariate survival analysis and Cox regression analysis. Any complications were recorded.

RESULTS

All patients were followed up for 24-72 months, with an average of (60 ± 13.0) months. At the last follow-up, based on the HHS, 25 patients (64.1%) reported excellent and good clinical outcomes. 29 patients (74.3%) achieved MCID. Imaging evaluation of the postoperative femoral head status showed that 6 cases improved, 20 cases remained stable, and 13 cases showed progressed. Out of 39 hips, 12 hips had postoperative clinical failure, resulting in a clinical success rate of 69.2%. Association Research Circulation Osseous (ARCO) stage, China-Japan Friendship Hospital (CJFH) classification, and postoperative crutch-bearing time are risk factors for clinical failure. Postoperative crutch-bearing time of less than 3 months is an independent risk factor for clinical failure. After surgery, there was one case of sciatic nerve injury and one case of heterotopic ossification. There were no infections or non-union of the greater trochanter osteotomy.

CONCLUSION

The SHD technique through the femoral head fovea fenestration and impaction bone grafting provides a safe and effective method for treating non-traumatic ONFH, with good mid-term clinical outcomes. ARCO staging, CJFH classification, and postoperative crutch-bearing time are risk factors that affect clinical outcomes after surgery and lead to further THA. Insufficient postoperative crutch-bearing time is an independent risk factor for clinical failure.

Astaxanthin-mediated Nrf2 activation ameliorates glucocorticoid-induced oxidative stress and mitochondrial dysfunction and impaired bone formation of glucocorticoid-induced osteonecrosis of the femoral head in rats

BACKGROUND

Osteonecrosis of the femoral head caused by glucocorticoids (GIONFH) is a significant issue resulting from prolonged or excessive clinical glucocorticoid use. Astaxanthin, an orange-red carotenoid present in marine organisms, has been the focus of this study to explore its impact and mechanism on osteoblast apoptosis induced by dexamethasone (Dex) and GIONFH.

METHODS

In this experiment, bioinformatic prediction, molecular docking and dynamics simulation, cytotoxicity assay, osteogenic differentiation, qRT-PCR analysis, terminal uridine nickend labeling (TUNEL) assay, determination of intracellular ROS, mitochondrial function assay, immunofluorescence, GIONFH rat model construction, micro-computed tomography (micro-CT) scans were performed.

RESULTS

Our research demonstrated that a low dose of astaxanthin was non-toxic to healthy osteoblasts and restored the osteogenic function of Dex-treated osteoblasts by reducing oxidative stress, mitochondrial dysfunction, and apoptosis. Furthermore, astaxanthin rescued the dysfunction in poor bone quality, bone metabolism and angiogenesis of GIONFH rats. The mechanism behind this involves astaxanthin counteracting Dex-induced osteogenic damage by activating the Nrf2 pathway.

CONCLUSION

Astaxanthin shields osteoblasts from glucocorticoid-induced oxidative stress and mitochondrial dysfunction via Nrf2 pathway activation, making it a potential therapeutic agent for GIONFH treatment.

Epidemiological investigation and diagnostic analysis of osteonecrosis of the femoral head in three northeastern provinces of China

BACKGROUND

In this retrospective case investigation, we analysed the data of patients with osteonecrosis of the femoral head (ONFH) to reveal demographic and clinical diagnostic features of ONFH in three northeastern provinces of China and provide a reference for its prevention, diagnosis, and treatment.

METHODS

We collected data from patients in Beijing Orthopaedic Hospital of Liaoning, focusing on the aetiology and diagnosis of ONFH. Medical records and self-designed questionnaires were used to collect information for statistical analysis, including age, aetiology, reason for glucocorticoid use, hospital level at first visit, and diagnosis.

RESULTS

In total, 906 patients with complete medical records were included in the analysis. The mean patient age was 47.65 ± 12.12 years. The peak age distribution was in the 40s for men and the 50s for women. Among the total cohort, 72 patients (7.95%; 40 men and 32 women) had traumatic ONFH, 198 (21.85%; 131 men and 67 women) had steroid-induced ONFH, 230 (25.39%; 121 men and 109 women) had idiopathic ONFH, and 406 (44.81%; 397 men and 9 women) had alcohol-induced ONFH. Six hundred and twenty patients were diagnosed with ONFH at the first visit, while 286 patients were misdiagnosed, with a diagnosis rate of 68.43%. The diagnosis rate at the first visit in tertiary hospitals was 76.14%. The diagnosis rate at the first visit in second-class hospitals was 52.07%.ONFH was most likely to be misdiagnosed as lumbar disc herniation.

CONCLUSIONS

Most patients with ONFH in three northeastern provinces of China were middle-aged, male, and had alcohol-induced ONFH. The misdiagnosis rate of ONFH at the first visit was very high, especially for misdiagnosis of lumbar disc herniation, indicating that the diagnosis of ONFH requires further improvement.

Research progress in the pathogenesis of hormone-induced femoral head necrosis based on microvessels: a systematic review

Hormonal necrosis of the femoral head is caused by long-term use of glucocorticoids and other causes of abnormal bone metabolism, lipid metabolism imbalance and blood microcirculation disorders in the femoral head, resulting in bone trabecular fracture, bone tissue necrosis collapse, and hip dysfunction. It is the most common type of non-traumatic necrosis of the femoral head, and its pathogenesis is complex, while impaired blood circulation is considered to be the key to its occurrence. There are a large number of microvessels in the femoral head, among which H-type vessels play a decisive role in the "angiogenesis and osteogenesis coupling", and thus have an important impact on the occurrence and development of femoral head necrosis. Glucocorticoids can cause blood flow injury of the femoral head mainly through coagulation dysfunction, endothelial dysfunction and impaired angiogenesis. Glucocorticoids may inhibit the formation of H-type vessels by reducing the expression of HIF-1α, PDGF-BB, VGEF and other factors, thus causing damage to the "angiogenesis-osteogenesis coupling" and reducing the ability of necrosis reconstruction and repair of the femoral head. Leads to the occurrence of hormonal femoral head necrosis. Therefore, this paper reviewed the progress in the study of the mechanism of hormone-induced femoral head necrosis based on microvascular blood flow at home and abroad, hoping to provide new ideas for the study of the mechanism of femoral head necrosis and provide references for clinical treatment of femoral head necrosis.

Relationship between lipid metabolism, coagulation and other blood indices and etiology and staging of non-traumatic femoral head necrosis: a multivariate logistic regression-based analysis

BACKGROUND

To analyze the relationship between lipid metabolism, coagulation function, and bone metabolism and the contributing factor and staging of non-traumatic femoral head necrosis, and to further investigate the factors influencing the blood indicators related to the staging of non-traumatic femoral head necrosis.

METHODS

The medical records of patients with femoral head necrosis were retrieved from the inpatient medical record management system, and the lipid metabolism, bone metabolism, and coagulation indices of non-traumatic femoral head necrosis (including alcoholic, hormonal, and idiopathic group) were obtained according to the inclusion and exclusion criteria, including Low-Density Lipoprotein Cholesterol, Triglycerides, Non-High-Density Lipoprotein Cholesterol, Apolipoprotein A1, Apolipoprotein (B), Apolipoprotein (E), Uric Acid, Alkaline Phosphatase, Bone-specific Alkaline Phosphatase, Activated Partial Thromboplastin Time, Prothrombin Time, D-dimer, Platelet count. The relationship between these blood indices and the different stages under different causative factors was compared, and the factors influencing the stages of non-traumatic femoral head necrosis were analyzed using multivariate logistic regression.

RESULTS

(i) Gender, Age and BMI stratification, Low-density Lipoprotein Cholesterol, Triglycerides, Non-High-density Lipoprotein Cholesterol, Apolipoprotein (B), Apolipoprotein (E), Uric Acid, Bone-specific Alkaline Phosphatase, Activated Partial Thromboplastin Time, Plasminogen Time, D-dimer, and Platelet count of the alcohol group were statistically different when compared among the different ARCO staging groups; (ii) The differences in Age and BMI stratification, Triglycerides, Non-High-density Lipoprotein Cholesterol, Apolipoprotein A1, Apolipoprotein B, Apolipoprotein E, Uric Acid, Bone-specific Alkaline Phosphatase, Activated Partial Thromboplastin Time, Plasminogen Time, D-dimer, and Platelet count were statistically significant when compared among the different phases in the hormone group (P < 0.05); (iii) The differences in Age and BMI stratification, Non-High-Density Lipoprotein Cholesterol, Apolipoprotein A1, Apolipoprotein (B), Apolipoprotein (E), Uric Acid, Activated Partial Thromboplastin Time, D-dimer, and Platelet count were statistically significant when compared among the different stages in the idiopathic group (P < 0.05); (v) Statistically significant indicators were included in the multivariate logistic regression analysis, excluding the highly correlated bone-specific alkaline phosphatase, and the results showed that Low-density lipoprotein was negatively correlated with changes in the course of ARCO, and Non-High-Density Lipoprotein cholesterol, Apo B, Activated Partial Thromboplastin Time, and Platelet count were significantly and positively correlated with disease progression.

CONCLUSION

An abnormal hypercoagulable state as well as an abnormal hyperlipidemic state are risk factors for the progression of non-traumatic femoral head necrosis under various exposure factors, as indicated by Non-High-Density Lipoprotein Cholesterol, Apolipoprotein B, Activated Fractional Thromboplastin Time, and Platelet Counts.

Exosomes derived from M2 macrophages prevent steroid-induced osteonecrosis of the femoral head by modulating inflammation, promoting bone formation and inhibiting bone resorption

Inflammatory reactions are involved in the development of steroid-induced osteonecrosis of the femoral head(ONFH). Studies have explored the therapeutic efficacy of inhibiting inflammatory reactions in steroid-induced ONFH and revealed that inhibiting inflammation may be a new strategy for preventing the development of steroid-induced ONFH. Exosomes derived from M2 macrophages(M2-Exos) display anti-inflammatory properties. This study aimed to examine the preventive effect of M2-Exos on early-stage steroid-induced ONFH and explore the underlying mechanisms involved. In vitro, we explored the effect of M2-Exos on the proliferation and osteogenic differentiation of bone marrow-derived mesenchymal stem cells(BMMSCs). In vivo, we investigated the role of M2-Exos on inflammation, osteoclastogenesis, osteogenesis and angiogenesis in an early-stage rat model of steroid-induced ONFH. We found that M2-Exos promoted the proliferation and osteogenic differentiation of BMMSCs. Additionally, M2-Exos effectively attenuated the osteonecrotic changes, inhibited the expression of proinflammatory mediators, promoted osteogenesis and angiogenesis, reduced osteoclastogenesis, and regulated the polarization of M1/M2 macrophages in steroid-induced ONFH. Taken together, our data suggest that M2-Exos are effective at preventing steroid-induced ONFH. These findings may be helpful for providing a potential strategy to prevent the development of steroid-induced ONFH.

m6A methylation modification and immune infiltration analysis in osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a elaborate hip disease characterized by collapse of femoral head and osteoarthritis. RNA N6-methyladenosine (m6A) plays a crucial role in a lot of biological processes within eukaryotic cells. However, the role of m6A in the regulation of ONFH remains unclear. In this study, we identified the m6A regulators in ONFH and performed subtype classification. We identified 7 significantly differentially expressed m6A regulators through the analysis of differences between ONFH and normal samples in the Gene Expression Omnibus (GEO) database. A random forest algorithm was employed to monitor these regulators to assess the risk of developing ONFH. We constructed a nomogram based on these 7 regulators. The decision curve analysis suggested that patients can benefit from the nomogram model. We classified the ONFH samples into two m6A models according to these 7 regulators through consensus clustering algorithm. After that, we evaluated those two m6A patterns using principal component analysis. We assessed the scores of those two m6A patterns and their relationship with immune infiltration. We observed a higher m6A score of type A than that of type B. Finally, we performed a cross-validation of crucial m6A regulatory factors in ONFH using external datasets and femoral head bone samples. In conclusion, we believed that the m6A pattern could provide a novel diagnostic strategy and offer new insights for molecularly targeted therapy of ONFH.

Comparison of outcomes after total hip arthroplasty between patients with osteonecrosis of the femoral head in Association Research Circulation Osseous stage III and stage IV: a five-year follow-up study

BACKGROUND

No large cohort study has evaluated the surgical outcomes of THA between different stages of ONFH patients. This study aimed to compare the surgical outcomes of ONFH patients who underwent THA in ARCO stage III versus IV, in terms of operative parameters, one-year hip function assessments and postoperative at least five-year complications, to inform optimized management of ONFH.

METHOD

From our prospectively collected database, 876 patients undergoing THA between October 2014 and April 2017 were analyzed and divided into ARCO stage III group (n = 383) and ARCO stage IV group(n = 493). Details of demographics, medical record information, adverse events and clinical scores of both groups were collected and compared. Proper univariate analysis was used for the analysis.

RESULT

There were no statistically significant differences in baseline characteristics between the two groups. Compared to ARCO stage IV patients, ARCO stage III patients showed a shorter operative time (p < 0.01), less bleeding (p < 0.01), fewer one-year readmissions (p = 0.026) and complications (p = 0.040), and significantly higher HHS (p < 0.01) one year after THA. In addition, ARCO stage IV patients seem more likely to suffer prosthesis dislocation (p = 0.031).

CONCLUSION

Although ARCO stage IV patients in the study cohorts appeared to suffer more one-year complications, no significant difference was observed at long-term follow-up. Enhanced clinical guidance on preventing early prosthesis dislocation may help improve the prognosis of final-stage ONFH patients.

Correlation of serum and local CXCL13 levels with disease severity in patients with non-traumatic osteonecrosis of femoral head

OBJECTIVE

The primary aim of the present study was to explore the potential correlation of serum / local CXCL13 expressions and disease severity in non-traumatic osteonecrosis of the femoral head (NT-ONFH).

METHODS

In total, NT-ONFH patients (n = 130) together with healthy controls (HCs, n = 130) were included in this investigation. Radiographic progression was evaluated based on the imaging criteria outlined in the ARCO classification system. To assess the diagnostic value of serum CXCL13 in relation to radiographic progression, Receiver operating characteristic (ROC) curve analysis was conducted. Serum CXCL13 levels were quantified utilizing ELISA in all participants. Furthermore, local protein/mRNA expressions of CXCL13 were examined employing immunohistochemistry, western blot, as well as RT-PCR techniques. Clinical severity was appraised using the visual analogue scale (VAS), Harris Hip Score (HHS), and Western Ontario as well as McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

The findings revealed a significant reduction in serum CXCL13 levels among NT-ONFH patients in contrast with HCs. Moreover, both mRNA and protein expressions of CXCL13 were markedly decreased in the necrotic area (NA) than the non-necrotic area (NNA) as well as the healthy femoral head tissues. Additionally, serum CXCL13 levels were substantially lower among patients classified as ARCO stage 4 than those at ARCO stage 3. The concentrations of CXCL13 in stage 3 patients were notably diminished relative to those at ARCO stage 2. Notably, serum CXCL13 levels demonstrated a negative association with ARCO grade. Furthermore, these levels were also inversely linked to VAS scores as well as WOMAC scores while displaying a positive association with HHS scores. The findings of ROC curve suggested that reduced serum CXCL13 levels could be an underlying indicator for ARCO stage.

CONCLUSIONS

The reduced levels of either serum CXCL13 or local CXCL13 were intricately linked to disease severity for patients with NT-ONFH.

The pandemic is gone but its consequences are here to stay: avascular necrosis following corticosteroids administration for severe COVID-19

BACKGROUND

In patients with COVID-19 infection and respiratory insufficiency, corticosteroid (CCS) administration is recommended. Among the wide range of complications and interactions, time-limited high-dose CCS administration might promote avascular necrosis (AVN) in a cumulative dose. This systematic review updated the current evidence and characterises the trend of AVN following time-limited high-dose CCS administration in patients who had severe COVID-19, discussing management strategies and outcomes.

METHODS

This systematic review was conducted according to the 2020 PRISMA statement. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Scopus restricting the search to the years 2019 to 2023. All the clinical studies which investigated the association between time-limited high-dose CCS administration in patients with severe COVID-19 infection and AVN were accessed.

RESULTS

A total of 245 patients (9 studies) who experienced AVN following COVID-19 were included in the present investigation. 26% (63 of 245 included patients) were women. The mean age of the patients was 42.9 ± 17.7 years. Four studies focused on AVN of the hip and two on the knee, and the other studies included patients with AVN from mixed areas of the body (spine, pelvis, and shoulder). The mean time elapsed from COVID-19 infection to the development of symptomatic AVN was 79.4 ± 59.2 days (range, 14 to 166 days).

CONCLUSION

It is possible that even time-limited high-dose CCS administration in patients with severe COVID-19 infection increased the incidence of AVN. The mean time elapsed from COVID-19 infection to the development of symptomatic AVN was approximately 80 days. Given the high risk of bias in all the included studies, the quality of recommendations of the present investigation is low, and no reliable conclusion can be inferred.

Analysis of the natural collapse course of non-traumatic osteonecrosis of the femoral head based on the matrix model

BACKGROUND

There are many predictions about the progression of natural collapse course of osteonecrosis of the femoral head. Here, we aimed to combine the three classical prediction methods to explore the progression of the natural collapse course.

METHODS

This retrospective study included 127 patients admitted to our hospital from October 2016 to October 2017, in whom the femoral head had not collapsed. Logistic regression analysis was performed to determine the collapse risk factors, and Kaplan-Meier survival curves were used for femoral head survival analysis. The collapse rate of the femoral head was recorded within 5 years based on the matrix model. The specificity of the matrix model was analyzed using the receiver operating characteristic curve.

RESULTS

A total of 127 patients with a total of 202 hips were included in this study, and 98 hips collapsed during the follow-up period. Multivariate logistics regression analysis showed that the predictive ability of the matrix model was stronger than Association Research Circulation Osseous staging, Japanese Investigation Committee classification, and area (P < 0.05). Kaplan-Meier survival curve showed that the median survival time of femoral head in patients was 3 years. The result of the receiver operating characteristic curve analysis showed that the area under the curve (AUC) of the matrix model had better predictive value (AUC = 0.771, log-rank test: P < 0.001).

CONCLUSION

We creatively combined the three classical prediction methods for evaluating the progression of the natural collapse course based on the matrix model and found that the higher the score of the matrix model, the higher the femoral head collapse rate. Specifically, the matrix model has a potential value in predicting femoral head collapse and guiding treatment selection.

Regenerative therapies for femoral head necrosis in the past two decades: a systematic review and network meta-analysis

BACKGROUND

Regenerative techniques combined with core decompression (CD) are commonly used to treat osteonecrosis of the femoral head (ONFH). However, no consensus exists on regeneration therapy combined with CD that performs optimally. Therefore, we evaluated six regenerative therapies combined with CD treatment using a Bayesian network meta-analysis (NMA).

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science databases. Six common regeneration techniques were categorized into the following groups with CD as the control group: (1) autologous bone graft (ABG), (2) autologous bone graft combined with bone marrow aspirate concentrate (ABG + BMAC), (3) bone marrow aspirate concentrate (BMAC), (4) free vascular autologous bone graft (FVBG), (5) expanded mesenchymal stem cells (MSCs), and (6) platelet-rich plasma (PRP). The conversion rate to total hip arthroplasty (THA) and progression rate to femoral head necrosis were compared among the six treatments.

RESULT

A total of 17 literature were included in this study. In the NMA, two of the six treatment strategies demonstrated higher response in preventing the progression of ONFH than CD: MSCs (odds ratio [OR]: 0.098, 95% confidence interval [CI]: 0.0087-0.87) and BMAC (OR: 0.27, 95% CI: 0.073-0.73). Additionally, two of the six treatment strategies were effective techniques in preventing the conversion of ONFH to THA: MSCs (OR: 0.062, 95% CI: 0.0038-0.40) and BMAC (OR: 0.32, 95% CI: 0.1-0.074). No significant difference was found among FVBG, PRP, ABG + BMAC, ABG, and CD in preventing ONFH progression and conversion to THA (P > 0.05).

CONCLUSIONS

Our NMA found that MSCs and BMAC were effective in preventing ONFH progression and conversion to THA among the six regenerative therapies. According to the surface under the cumulative ranking value, MSCs ranked first, followed by BMAC. Additionally, based on our NMA results, MSCs and BMAC following CD may be necessary to prevent ONFH progression and conversion to THA. Therefore, these findings provide evidence for the use of regenerative therapy for ONFH.

Exploring molecular mechanisms of intra-articular changes in osteonecrosis of femoral head using DIA proteomics and bioinformatics

PURPOSE

This study is aimed to delve into the crucial proteins associated with hormonal osteonecrosis of the femoral head (ONFH) and its intra-articular lesions through data-independent acquisition (DIA) proteomics and bioinformatics analysis.

METHODS

We randomly selected samples from eligible ONFH patients and collected samples from the necrotic area of the femoral head and load-bearing cartilage. The control group comprised specimens from the same location in patients with femoral neck fractures. With DIA proteomics, we quantitatively and qualitatively tested both groups and analyzed the differentially expressed proteins (DEPs) between groups. Additionally, we enriched the analysis of DEP functions using gene ontology terms and Kyoto Encyclopedia of Genes and Genomes pathways and verified the key proteins in ONFH through Western blot.

RESULTS

Proteomics experiment uncovered 937 common DEPs (422 upregulated and 515 downregulated) between the two groups. These DEPs mainly participate in biological processes such as hidden attributes, catalytic activity, molecular function regulators, and structural molecule activity, and in pathways such as starch and sucrose metabolism, ECM-receptor interaction, PI3K-Akt signaling, complement and coagulation cascades, IL-17 signaling, phagosome, transcriptional misregulation in cancers, and focal adhesion. Through protein-protein interaction network target gene analysis and Western blot validation, we identified C3, MMP9, APOE, MPO, LCN2, ELANE, HPX, LTF, and THBS1 as key proteins in ONFH.

CONCLUSIONS

With DIA proteomics and bioinformatics analysis, this study reveals the molecular mechanisms of intra-articular lesions in ONFH. A correlation in the necrotic area and load-bearing cartilage of ONFH at ARCO stages IIIB-IV as well as potential key regulatory proteins was identified. These findings will help more deeply understand the pathogenesis of ONFH and may provide important clues for seeking more effective treatment strategies.

Network meta-analysis of invasive treatment for early-stage osteonecrosis of the femoral head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a common disabling disease in orthopedics. Blocking the progression of ONFH in the early stage is essential for avoiding total hip replacement.

PURPOSES

The purpose of this study is to evaluate the effect of invasive treatment on early-stage ONFH.

METHODS

According to the PRISMA guidelines, relevant English databases were searched in August 2022 to collect published research. Extract result indicators and conduct network meta-analysis using R software.

RESULTS

A total of 15 RCTs were included. All patients were diagnosed with early-stage ONFH. The surface under the cumulative ranking curve (SUCRA) showed that CD + BMMSC and CD + PRP were the most effective in improving HHS. The results of the league table showed that CD + BMMSC was superior to CD alone. Meanwhile, the SUCRA for FR showed that CD + BG + BMMSC was the most likely to be the most effective in reducing FR. The league table revealed that CD + BG, CD + BG + BMMSC, and CD + BMMSC were superior to CD alone, with statistically significant differences.

CONCLUSION

Considering the HHS and FR, CD + BMMSC may be the optimal treatment option to effectively delay the progression of ONFH and restore the postoperative function of patients.

REGISTRATION NUMBER

The study protocol has been registered on the PROSPERO platform (CRD42023380169).

No evidence of genetic causality between diabetes and osteonecrosis: a bidirectional two-sample Mendelian randomization analysis

OBJECTIVE

This study aimed to examine whether diabetes mellitus is causally associated with osteonecrosis.

METHOD

Using publicly accessible genome-wide association study statistics, a bidirectional two-sample Mendelian randomization analysis was carried out. In order to determine whether diabetes has a causal effect on osteonecrosis and whether osteonecrosis has a causal effect on diabetes, we extracted six date on diabetes in Europeans from IEU OpenGWAS and GWAS Catalogue and osteonecrosis in Europeans from FinnGen. We then evaluated the data using inverse variance weighting, MR-Egger regression, weighted median, weighted mode, and simple mode. The results' stability and dependability were then evaluated using sensitivity analysis and heterogeneity analysis. Finally, meta-analysis is used to further confirm if there is a relationship between diabetes and osteonecrosis.

RESULTS

When diabetes was used as an exposure factor, MR-Egger regression showed that directional fold product was unlikely to bias the results. Cochran's Q test showed only minor heterogeneity in a few data sets. Multidirectional tests Egger-intercept, MR-PRESSO and funnel plots for most data did not show multidirectional and asymmetry at the gene level. Most of the IVW results showed no causal relationship between diabetes mellitus and osteonecrosis. The results of meta-analysis of IVW methods further confirmed the absence of a causal relationship. Inverse MR analysis also showed no causal relationship between osteonecrosis and diabetes.

CONCLUSION

Results of bidirectional MR analysis show no evidence of causal relationship between diabetes and osteonecrosis.

Correlation between ESR1 and APOE gene polymorphisms and risk of osteonecrosis of the femoral head: a case-control study

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a disease with a high disability rate, and genetic factors are closely related to its pathogenesis. This study aimed to investigate the possible correlation between ESR1 and APOE gene polymorphisms and the risk of ONFH.

METHODS

In this case-control study, the potential association between three genetic variants (rs2982573 C < T, rs10872678 C < T, and rs9322332 A < C) of the ESR1 gene and two genetic variants (rs7259620 A < G and rs769446 C < T) of the APOE gene with the risk of ONFH was investigated. Correlations between gene polymorphisms and ONFH risk were assessed using logistic regression analysis, with calculation of odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The overall analysis demonstrated that rs9322332 in the ESR1 gene exhibited a correlation with a decreased risk of ONFH under the homozygous (AA vs.CC: OR = 0.69, 95% CI [0.53-0.90], p = 0.006), dominant (CA + AA vs. CC: OR = 0.70, 95% CI [0.54-0.90], p = 0.006), and additive (OR = 0.79, 95% CI [0.66-0.95], p = 0.013) models. The stratification analysis revealed that rs9322332 was linked to a lower risk of ONFH in subgroups characterized by individuals aged over 51 years and non-smokers. Nevertheless, there were no notable correlations found between ESR1 rs2982573 and rs10872678, as well as APOE rs7259620 and rs769446, with the risk of ONFH.

CONCLUSION

ESR1-rs9322332 is closely linked to a decreased risk of ONFH, thereby enhancing our understanding of the relationship between gene polymorphisms and ONFH.

Comparative analysis of surgical interventions for osteonecrosis of the femoral head: a network meta-analysis of randomized controlled trials

BACKGROUND

Despite several surgical options, there remains no consensus regarding the optimal approach for osteonecrosis of the femoral head (ONFH), a prevalent and refractory disease. To determine the most suitable treatment modality, we compared randomized controlled trials (RCTs) that evaluated multiple surgical treatments for ONFH using a Bayesian network meta-analysis (NMA).

METHODS

The outcomes of 11 different surgical treatments were assessed using NMA comparisons of the rate of progression of femoral head necrosis, the rate of conversion to total hip arthroplasty, and improvement of the Harris hip score (HHS). A random effects model was used to analyze the odds ratio (OR) or mean difference, and risk of bias was assessed using the Cochrane risk of bias assessment tool for randomized trials. The confidence of the results was assessed using the confidence in network meta-analysis tool.

RESULTS

A total of 18 RCTs were included in the meta-analysis. Compared with core decompression (CD), the forest plot showed that autologous bone grafting (ABG), free fibula grafting (FFG), vascularized bone grafting (VBG), autologous bone grafting combined with bone marrow aspirate concentrate (ABG + BMAC), and biomaterial grafting combined with vascularized bone grafting (BMG + VBG) delayed ONFH progression. Among them, ABG + BMAC showed the most promising results (OR 0.019; 95% confidence interval [CI] 0.0012-0.25). However, upon comparing CD with different surgical modalities, no significant differences were found in preventing total hip arthroplasty. Furthermore, we cannot draw conclusions regarding the HHS due to attribution and high heterogeneity across the studies.

CONCLUSION

Overall, ABG, VBG, FFG, ABG + BMAC, and BMG + VBG showed significant results in preventing ONFH progression compared with that shown by CD. Based on the surface under the cumulative ranking, ABG + BMAC was the most effective. Moreover, all treatments involving bone grafting were found to be effective, possibly indicating the necessity of its use in the treatment of ONFH.

Systematic analysis of hip-preserving treatment for early osteonecrosis of the femoral head from the perspective of bibliometrics (2010-2023)

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a serious condition that causes bone tissue death, femoral head collapse, and hip joint destruction. Early intervention through hip-preserving treatment is crucial to slow down disease progression, preserve hip joint function, and improve the quality of life of patients. We analyzed the knowledge map, research gaps, and future research directions in the field of hip-preserving treatment for early ONFH.

METHODS

All publications related to hip-preserving treatment for early ONFH published between 2010 and 2023 were identified from the Web of Science Core Collection and analyzed using VOSviewer 1.6.19, CiteSpace 6.2.R2, and Scimago Graphica 1.0.35.

RESULTS

In total, 234 articles were analyzed. The results showed an exponential growth trend in the number of publications related to hip-preserving treatment for early ONFH in the past decade. China and the USA were the main contributors. International Orthopaedics published the most papers in this field, whereas Bone and Joint Surgery-American Volume had the highest average citation count per article. Several stable research topics were noted in this field, including core decompression (CD), osteotomy, bone transplantation in hip-preserving surgery, and cell therapy, which have become research hotspots in hip-preserving treatment.

CONCLUSIONS

Hip-preserving treatment for early ONFH has received increasing attention, and research in this field is expected to grow. Stable research topics include core decompression (CD), osteotomy, bone transplantation, and cell therapy. Future research is predicted to focus on cell therapy and combination therapy, resulting in an increasing number of publications on hip-preserving treatment for early ONFH.

Exosomes from bone marrow mesenchymal stem cells ameliorate glucocorticoid-induced osteonecrosis of femoral head by transferring microRNA-210 into bone microvascular endothelial cells

OBJECTIVES

Bone microvascular endothelial cells (BMECs) played an important role in the pathogenesis of glucocorticoid-induced osteonecrosis of femoral head (GCS-ONFH), and exosomes derived from bone marrow mesenchymal stem cells (BMSC-Exos) may provide an effective treatment. This study aimed to evaluate the effects of BMSC-Exos and internal microRNA-210-3p (miRNA-210) on GCS-ONFH in an in vitro hydrocortisone-induced BMECs injury model and an in vivo rat GCS-ONFH model.

METHODS

BMECs, BMSCs and BMSC-Exos were isolated and validated. BMECs after the treatment of hydrocortisone were cocultured with different concentrations of BMSC-Exos, then proliferation, migration, apoptosis and angiogenesis of BMECs were evaluated by CCK-8, Annexin V-FITC/PI, cell scratch and tube formation assays. BMSCs were transfected with miRNA-210 mimics and miRNA-210 inhibitors, then BMSC-ExosmiRNA-210 mimic and BMSC-ExosmiRNA-210 inhibitor secreted from such cells were collected. The differences between BMSC-Exos, BMSC-ExosmiRNA-210 mimic and BMSC-ExosmiRNA-210 inhibitor in protecting BMECs against GCS treatment were analyzed by methods mentioned above. Intramuscular injections of methylprednisolone were performed on Sprague-Dawley rats to establish an animal model of GCS-ONFH, then tail intravenous injections of BMSC-Exos, BMSC-ExosmiRNA-210 mimic or BMSC-ExosmiRNA-210 inhibitor were conducted after methylprednisolone injection. Histological and immunofluorescence staining and micro-CT were performed to evaluate the effects of BMSC-Exos and internal miRNA-210 on the in vivo GCS-ONFH model.

RESULTS

Different concentrations of BMSC-Exos, especially high concentration of BMSC-Exos, could enhance the proliferation, migration and angiogenesis ability and reduce the apoptosis rates of BMECs treated with GCS. Compared with BMSC-Exos, BMSC-ExosmiRNA-210 mimic could further enhance the proliferation, migration and angiogenesis ability and reduce the apoptosis rates of BMECs, while BMECs in the GCS + BMSC-ExosmiRNA-210 inhibitor group showed reduced proliferation, migration and angiogenesis ability and higher apoptosis rates. In the rat GCS-ONFH model, BMSC-Exos, especially BMSC-ExosmiRNA-210 mimic, could increase microvascular density and enhance bone remodeling of femoral heads.

CONCLUSIONS

BMSC-Exos containing miRNA-210 could serve as potential therapeutics for protecting BMECs and ameliorating the progression of GCS-ONFH.

Analysis of the efficacy of drilling decompression autologous bone marrow and allogeneic bone grafting in the treatment of HIV-positive patients with early osteonecrosis of the femoral head

OBJECTIVE

To investigate the efficacy of treating patients with HIV-positive osteonecrosis of the femoral head using drilled decompression autologous bone marrow and allogeneic bone grafting.

METHODS

40 patients (44 hips) with early osteonecrosis of the femoral head treated by drilling decompression autologous bone marrow and allogeneic bone grafting since October 2015 were retrospectively analyzed, among which 20 patients (24 hips) were HIV-positive patients with early osteonecrosis of the femoral head, 16 males and 4 females, age 22-43 years, average 39.6 ± 10.18 years, and 20 patients (20 hips) in the same period HIV-negative early osteonecrosis of the femoral head patients, 13 males and 7 females, aged 48-78 years, mean 63.50 ± 7.94 years were negative controls. General information including ARCO stage, Harris score, VAS score, hematological indexes including CD4+ T lymphocyte count, and HIV viral load was recorded for all patients before surgery. All patients were operated on by drilling and decompression of the necrotic area, harvesting autologous iliac bone marrow with allogeneic bone, and bone grafting through the decompression channel. The patients were followed up regularly at 6, 12, and 24 months after surgery and annually thereafter, and the repair of the necrotic femoral head was observed by reviewing the frontal and lateral X-ray, CT or MRI of the hip joint, and the complications and functional recovery of the hip joint was counted and compared between the two groups.

RESULTS

All patients were followed up, and the ARCO stages in the HIV-positive group were stage I 2 hips, stage IIA 6 hips, stage IIB 8 hips, stage IIC 6 hips, and stage III 2 hips, with a follow-up time of 12 to 60 months and a mean of 24.6 months. In the negative control group, there were 3 hips in ARCO stage I, 7 hips in stage IIA, 5 hips in stage IIB, 3 hips in stage IIC, and 2 hips in stage III, and the follow-up time ranged from 13 to 62 months, with an average of 24.8 months. The Harris score and VAS score of the hip in both groups improved significantly at 6 months postoperatively compared with those before surgery (P < 0.001). The difference between the Harris score of the hip in the positive group at 24 months postoperatively compared with that at 6 months postoperatively was statistically significant, but the VAS score at 24 months postoperatively compared with that at 6 months postoperatively was not statistically significant. In the negative group, there was no statistically significant difference in the Harris score and VAS score of the hip at 24 months postoperatively compared with those at 6 months postoperatively. In the positive group, there was a trend of continuous increase in hip BMD from the beginning of the postoperative period (P < 0.001). There was no statistically significant difference between the negative group and the positive group at the 24 months postoperatively follow-up except for the Harris score, which was statistically significant (P < 0.001), and the VAS score, which was statistically insignificant. At the 24 months postoperatively follow-up, patients in both groups had good recovery of hip function, and no complications such as vascular and nerve injury and fracture occurred during the perioperative period and follow-up period, and no complications related to incisional infection and pulmonary infection occurred during hospitalization.

CONCLUSION

The treatment of early HIV-positive osteonecrosis of the femoral head patients with autologous bone marrow and allogeneic bone grafting by drilling and decompression to remove the tissue in the necrotic area of the femoral head can effectively stop the process of osteonecrosis of the femoral head and promoting femoral head repair in HIV-positive patients is a safe and effective method for treating HIV-positive patients with early osteonecrosis of the femoral head, and can effectively delay or postpone total hip replacement in patients.

Knowledge mapping of programmed cell death in osteonecrosis of femoral head: a bibliometric analysis (2000-2022)

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a common, refractory and disabling disease of orthopedic department, which is one of the common causes of hip pain and dysfunction. Recent studies have shown that much progress has been made in the research of programmed cell death (PCD) in ONFH. However, there is no bibliometric analysis in this research field. This study aims to provide a comprehensive overview of the knowledge structure and research hot spots of PCD in ONFH through bibliometrics.

METHOD

The literature search related to ONFH and PCD was conducted on the Web of Science Core Collection (WoSCC) database from 2002 to 2021. The VOSviewers, "bibliometrix" R package and CiteSpace were used to conduct this bibliometric analysis.

RESULTS

In total, 346 articles from 27 countries led by China and USA and Japan were included. The number of publications related to PCD in ONFH is increasing year by year. Shanghai Jiao Tong University, Xi An Jiao Tong University, Wuhan University and Huazhong University of Science and Technology are the main research institutions. Molecular Medicine Reports is the most popular journal in the field of PCD in ONFH, and Clinical Orthopaedics and Related Research is the most cocited journal. These publications come from 1882 authors among which Peng Hao, Sun Wei, Zhang Chang-Qing, Zhang Jian and Wang Kun-zheng had published the most papers and Ronald S Weinstein was cocited most often. Apoptosis, osteonecrosis, osteonecrosis of the femoral head, glucocorticoid and femoral head appeared are the main topics the field of PCD in ONFH. Autophagy was most likely to be the current research hot spot for PCD in ONFH.

CONCLUSION

This is the first bibliometric study that comprehensively summarizes the research trends and developments of PCD in ONFH. This information identified recent research frontiers and hot directions, which will provide a reference for scholars studying PCD in ONFH.

Return to work status of patients under 65 years of age with osteonecrosis of the femoral head after total hip arthroplasty

OBJECTIVE

This aimed to evaluate the status of return to work (RTW) in patients with osteonecrosis of the femoral head (ONFH) after total hip arthroplasty (THA).

METHODS

The baseline characteristics of all patients in this retrospective study were obtained from the hospital patient database. The relevant changes in patients' working conditions, as well as the numerical rating scale (NRS), Harris Hip Score (HHS), self-assessment of work ability, and Likert scale satisfaction assessment were obtained through video call follow-ups.

RESULTS

118 patients (response rate: 83%) were ultimately included in this study. The average length of time for the patients to stop working preoperatively was 20.7 weeks. Ninety-four patients (24 women and 70 men) who underwent THA had RTW status, with a mean RTW time of 21.0 weeks. Men had a significantly higher proportion of final RTW and a significantly faster RTW than women. Significant differences in smoking, drinking, cardiovascular diseases, changes in working levels, variations in the types of physical work, changes in working hours, and pain symptoms were observed between the RTW and Non-RTW populations. The patients with a positive RTW status had higher postoperative HHS scores, lower postoperative NRS scores, and higher self-assessment of work ability than patients who had a negative RTW status.

CONCLUSION

Ultimately, 80% of patients achieved RTW status. Drinking, sex, change in working level, variation in the type of physical work, change in working hours, post-surgery HHS score and self-assessment of work ability can serve as predictive factors for RTW.

Laboratory indices in patients with osteonecrosis of the femoral head: a retrospective comparative study

BACKGROUND

Osteonecrosis of the femoral head is a degenerative condition linked to corticosteroids, alcoholism, or trauma. With its rising prevalence due to increased hormone drug use and its debilitating effects on young to middle-aged individuals, understanding its association with specific laboratory indicators can aid early diagnosis and prevention.

METHODS

Upon retrospective analysis of the clinical data pertaining to individuals diagnosed with femoral head necrosis, spanning from January 2016 to January 2022, a comprehensive evaluation was conducted within the same time frame. The study aimed to ascertain the presence of femoral head necrosis in a total of 1176 individuals. A total of 1036 healthy patients were recruited randomly, ensuring that their ages matched. The risk variables associated with the utilization of logistic regression analysis and analysis techniques are employed. The patient examines the age distribution within a specific age group.

RESULTS

The levels of high-density lipoprotein, low-density lipoprotein A1, lipoprotein B1, total protein, albumin, globulin, and other lipophilic metabolism and coagulation markers exhibited a statistically significant increase compared to the control group. A multifactor logistic regression analysis was conducted to identify potential risk factors associated with femoral head necrosis in patients.

CONCLUSION

Femoral head necrosis is associated with a range of variables including coagulation malfunction, lipid metabolic abnormalities, and inflammation.

Decreased serum 4-Hydroxynonenal level as a biomarker for the progression of steroid-induced osteonecrosis of the femoral head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is becoming a prevalent global health problem. 4-Hydroxynonenal (4-HNE) serves as a common marker of oxidative stress. This study aims to study the potential role of 4-HNE in the progression of steroid-induced osteonecrosis of the femoral head (SIONFH).

METHOD

Between April 2021 and December 2021, 64 subjects were enrolled in this cross-sectional case‒control study. Thirty-six patients were grouped based on the Association Research Circulation Osseous (ARCO) classification, and 28 healthy volunteers without hip pain or any lesions shown in anteroposterior and frog-leg lateral pelvic radiographs served as the normal control group. Bone hematoxylin-eosin (HE) staining, microcomputed tomography (micro-CT), immunohistochemistry, and levels of plasma 4-HNE were evaluated.

RESULTS

The 4-HNE level was higher in the SIONFH group than in the normal control group (P < 0.001), and 4-HNE levels were significantly higher in SIONFH patients in the early stage of disease (stage II). The 4-HNE level was negatively correlated with ARCO stage (r = - 0.6875, P < 0.001). Immunohistochemistry revealed the presence of 4-HNE in the trabecular bone, osteocytes, and bone marrow.

CONCLUSION

The 4-HNE level is negatively associated with ARCO stages. Lower levels of 4-HNE may serve as a critical biomarker for the progression of SIONFH.

Experimental study of a 3D-printing technique combined with biphasic calcium phosphates to treat osteonecrosis of the femoral head in a canine model

OBJECTIVE

This study was aimed to use a digital design of 3D-printing technology to create a surgical navigation template. At the same time, biphasic calcium phosphate (BCP) was applied to treat osteonecrosis of the femoral head (ONFH) in animal models, based on accurate positioning of necrotic lesions in the navigation templates and observation of its therapeutic effect.

METHODS

Fifteen healthy adult male and female beagle dogs weighing 20 + 2 kg were randomly divided into three groups (n = 5) after establishing a model of ONFH using the liquid nitrogen freezing method. Each model underwent necrotic lesion creation and BPC implantations on one side of the femoral head and only necrotic lesion creation on the other side of the femoral head. Each group underwent CT examination, gross observation, histological examination and immunohistochemical staining at 6 weeks, 12 weeks and 18 weeks postoperatively.

RESULTS

At weeks 6, 12, and 18, CT and gross examination showed that the necrotic area in the experimental group was basically intact and had been completely raised by BCP material. In the control group, there were signs of bone repair in the femoral head, but there were still large bone defects and cavities. At week 18, extensive collapse of the cartilage surface was observed. Through histological examination, in the experimental group at 12 and 18 weeks, a large number of new and reconstructed bone trabeculae containing a large amount of collagen fibres were observed (P < 0.05), while in the control group, there was extensive necrosis of the bone trabeculae without cellular structural areas. Immunohistochemical examination observation: A large number of CD31-positive cells were observed in the experimental group at 6 weeks, gradually decreasing at 12 and 18 weeks (P < 0.05), while a small number of CD31-positive cells were observed in the control group at 18 weeks.

CONCLUSION

The 3D-printed navigation template can accurately locate ONFH lesions. Implantation of BCP material can effectively play a supporting role, prevent the collapse of the loading surface, and induce bone formation and angiogenesis to some extent.

Efficacy and safety of traditional Chinese medicine in the treatment of osteonecrosis of the femoral head

BACKGROUND

Hip joint-preserving treatment options for osteonecrosis of the femoral head (ONFH) have been a research hotspot in recent years. The combination of Chinese and Western medicine has been used in clinical practice to treat early- and mid-stage ONFH. However, there is still a lack of high-quality evidence to verify the effectiveness and safety of this approach.

OBJECTIVE

To systematically evaluate the clinical efficacy and safety of the combination of traditional Chinese medicine (TCM) with Western medicine in the treatment of early- and mid-stage ONFH.

METHODS

Multiple electronic databases were searched to identify the randomized controlled trials (RCTs) examining the use of TCM in the treatment of ONFH. Based on the inclusion and exclusion criteria, eligible studies were selected, and the quality of the studies was evaluated using the risk of bias assessment tool recommended by the Cochrane system Evaluator manual 5.1.0. The meta-analysis of the included data was performed using Review Manager 5.4.1 software and Stata 17.0 software.

RESULTS

A total of 47 RCTs involving 3266 subjects were included in the meta-analysis. The results are observed: (1) Harris score: TCM + Western medicine versus Western medicine (SMD = 1.25, 95% Cl: 1.02 to 1.48, P < 0.00001), TCM + physiotherapy versus physiotherapy (SMD = 2.26, 95% Cl: 1.42 to 3.10, P < 0.00001), and TCM + hip preservation surgery versus hip preservation surgery (SMD = 1.28, 95% Cl: 1.03 to 1.53, P < 0.00001); (2) Visual analogue scale score: TCM + Western medicine versus Western medicine (SMD = -3.99, 95% Cl: -7.41 to -0.57, P = 0.02), TCM + physiotherapy versus physiotherapy (SMD = -0.99, 95% Cl: -1.44 to -0.54, P < 0.0001), and TCM + hip preservation surgery versus hip preservation surgery (SMD = -1.08, 95% Cl: -1.75 to -0.40, P = 0.002); (3) Imaging improvement: TCM + physiotherapy versus physiotherapy (RR = 1.42, 95% Cl: 1.15 to 1.76, P = 0.001) and TCM + hip preservation surgery versus hip preservation surgery (RR = 1.21, 95% Cl: 1.11 to 1.31, P < 0.0001); and (4) Occurrence of adverse reaction: TCM + Western medicine versus Western medicine (RR = 0.73, 95% Cl: 0.28 to 1.92, P = 0.53), TCM + physiotherapy versus physiotherapy (RR = 0.46, 95% Cl: 0.03 to 7.33, P = 0.58), and TCM + hip preservation surgery versus hip preservation surgery (RR = 1.11, 95% Cl: 0.36 to 3.45, P = 0.86).

CONCLUSION

TCM combined with Western medicine is an effective and safe approach for the treatment of ONFH. However, due to the low quality and quantity of the included studies, additional large-scale, high-quality studies are required to verify the above conclusions.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/#recordDetails , CRD42023392030.

A novel animal model of osteonecrosis of the femoral head based on 3D printing technology

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a prevalent orthopedic condition characterized by the disruption of blood supply to the femoral head, leading to ischemia of internal tissues, subchondral bone fractures, necrosis, and eventual collapse of the weight-bearing portion of the femoral head. This condition results in severe functional impairment, pain, and even disability of the hip joint. Existing animal models of ONFH have limitations in replicating the natural disease progression accurately. Thus, there is a critical need to develop a novel animal model capable of better simulating localized pressure on the human femoral head to facilitate ONFH-related research.

METHODS

In this study, we present a novel approach for modeling ONFH, which involves integrating stress factors into the modeling process through the utilization of 3D printing technology and principles of biomechanics. A total of 36 animals were randomly assigned to six groups, where they received either the novel modeling technique or the traditional hormone induction method. Subsequently, an 8-week treatment period was implemented, followed by conducting micro-CT scans and histological evaluations to assess tissue outcomes.

RESULTS

The study evaluated the cytotoxicity of the material used in the new model, and it was observed that the material did not exhibit any cytotoxic effects on cells. Additionally, the novel model successfully replicated the pathological features of ONFH, including femoral head collapse, along with a substantial presence of empty bone lacunae, cartilage defects, and subchondral bone fractures in the subchondral bone region.

CONCLUSION

In conclusion, our study provides evidence that the new model shows the ability to simulate the progression of the disease, making it a valuable tool for research in this field and can contribute to the development of better treatment strategies for this debilitating condition. It holds great promise for advancing our understanding of the pathogenesis of ONFH and the potential therapeutic interventions for this challenging clinical problem.

Stem cell therapy combined with core decompression versus core decompression alone in the treatment of avascular necrosis of the femoral head: a systematic review and meta-analysis

INTRODUCTION

Accumulated clinical trials had been focused on stem cell therapy in combination of core decompression (CD) in the treatment of avascular necrosis of the femoral head (ANFH). Nonetheless, the results were inconclusive. Here, we performed a systematic review and meta-analysis of previous randomized controlled trials (RCTs) and retrospective studies to assess whether combined stem cell augmentation with CD improved the outcomes of ANFH compared with CD alone.

METHODS

The current study included 11 RCTs and 7 retrospective studies reporting the clinical outcomes of a total of 916 patients and 1257 hips. 557 and 700 hips received CD and CD plus stem cell therapy, respectively. To compare CD with CD plus stem cell therapy, we examined the clinical evaluating scores, the occurrence of the femoral head, radiologic progression and conversion to total hip arthroplasty (THA).

RESULTS

Only 10 studies reported significantly greater improvement in hip functions while combining stem cell procedure with CD. The pooled results in subgroup analysis indicated that stem cell group had a lower collapse rate on a mid-term basis (P = 0.001), when combined with mechanical support (P < 0.00001), and with extracted stem cells (P = 0.0002). Likewise, stem cell group had a lower radiographic progression rate at 2- to 5-year follow-up [P = 0.003], when combined with structural grafting (P < 0.00001), and with extracted stem cells (P = 0.004). Stem cell therapy resulted in an overall lower THA conversion rate (P < 0.0001) except that at a follow-up longer than 5 years.

CONCLUSION

Stem cell therapy combined with core decompression was more effective in preventing collapse, radiographic progression and conversion to THA. Trial Registration The current protocol has been registered in PROSPERO with the registration number: CRD42023417248.

Biodegradable magnesium screw, titanium screw and direct embedding fixation in pedicled vascularized iliac bone graft transfer for osteonecrosis of the femoral head: a randomized controlled study

BACKGROUND

The use of degradable magnesium screws to fix the bone flap implanted in the treatment of femoral head necrosis has achieved preliminary good therapeutic results. However, there is no conclusive evidence in the study to demonstrate whether biodegradable magnesium screws promote angiogenesis and no comparison has been made between degradable magnesium screws and traditional screws.

OBJECTIVE

To investigate the clinical efficacy and safety of biodegradable magnesium screws in pedicled vascularized iliac bone graft transfer (PVIBGT) for osteonecrosis of the femoral head (ONFH).

MATERIALS AND METHODS

A total of thirty-six patients (37 hips) with ONFH were recruited from March 2020 to July 2022. The study used a single-blind method, and patients who underwent PVIBGT were randomized into three groups: 12 patients (12 hips) were fixed with biodegradable magnesium screws (Group A), 12 patients (13 hips) were fixed with titanium screws (Group B), 12 patients (12 hips) were directly embedded (Group C). The operating time and the length of stay were recorded. Harris scores, radiological examinations (X-ray, CT, DCE-MRI), blood and serum tests were conducted before and after surgery. The gas yield and degradation rates of the magnesium screws were measured at the 3-months and 6-months post-operative follow-ups in Group A.

RESULTS

There was no statistically significant difference among these three groups in terms of types, gender, age, course of disease, surgical side, operation time, the length of stay (P > 0.05). All patients were followed up for 6 months. The mean Harris scores were higher in all groups 6 months after surgery (P < 0.05). The rates of excellent and good outcomes were 66.7%, 46.2%, and 33.3% in Groups A, B, and C, respectively. PVIBGT and magnesium screws can improve the blood supply of the femoral head via DCE-MRI evaluation. Two patients with poor incision healing received prompt treatment and subsequently recovered well. No adverse events, such as hip infection or deep vein thrombosis, were reported in the patients. The patients had good biocompatibility of magnesium screws, and no fracture of the magnesium screws was observed in Group A. Liver and kidney functions (including serum magnesium) were within normal ranges. The area of the intermuscular air space was 0 cm² in follow-ups. The degradation rate of the biodegradable magnesium screws was approximately 10.32% at the 3-months follow-up and 13.72% at the 6-months follow-up.

CONCLUSIONS

PVIBGT has a positive effect, especially with regard to improving blood supply of the femoral head. The fixation of biodegradable magnesium screws is reliable and safe in PVIBGT, and promote angiogenesis.

Tanshinone I alleviates steroid-induced osteonecrosis of femoral heads and promotes angiogenesis: in vivo and in vitro studies

BACKGROUND

The impaired blood supply to the bones is an important pathological feature of steroid-induced osteonecrosis of the femoral head (SIONFH). Danshen is a Chinese herb that shows therapeutic effects on SIONFH, but the effects of one of its major bioactive constituents, Tanshinone I (TsI), on SIONFH remain unknown. Here, we evaluated the effects of TsI on SIONFH, particularly focusing on its effects on angiogenesis, in in vivo and in vitro research.

METHODS

SIONFH was induced in Sprague-Dawley rats by an intramuscular injection of methylprednisolone (40 mg/kg) in combination with an intraperitoneal injection of lipopolysaccharide (20 μg/kg). Morphological alterations of the femoral head were observed by dual-energy X-ray absorptiometry and HE staining. Western blot, qRT-PCR, and immunohistochemical/immunofluorescence staining were used to determine gene expression.

RESULTS

TsI (10 mg/kg) alleviated bone loss and rescued the expression of angiogenesis-related molecules (CD31, VWF, VEGF, and VEGFR2) in the femoral heads of SIONFH rats. Notably, TsI rescued the down-regulated expression of SRY-box transcription factor 11 (SOX11) in CD31⁺ endothelial cells in the femoral heads of SIONFH rats. In vitro studies showed that TsI preserved the dexamethasone-harmed angiogenic property (migration and tube formation) of human umbilical vein cells (EA.hy926), suppressed dexamethasone-induced cell apoptosis, reduced pro-apoptotic proteins (cytosolic cytochrome C, Bax, and caspase 3/9) and increased anti-apoptotic protein Bcl-2, whereas silencing of SOX11 reversed these beneficial effects.

CONCLUSIONS

This study demonstrates that TsI alleviates SIONFH and promotes angiogenesis by regulating SOX11 expression. Our work would provide new evidence for the application of TsI to treat SIONFH.