Symptomatic Multifocal Osteonecrosis: A Multicenter Study

A Current Review in the Orthopedic Management of Osteonecrosis of the knee Secondary to Treatment of Pediatric Hematologic Malignancy

Acute Lymphoblastic Leukemia is the most prevalent pediatric hematologic malignancy. The treatment for this illness has advanced significantly, now touting a 90% cure rate. Although these patients often become disease free, treatment can leave devastating effects that last long after their disease burden is alleviated. A commonly experienced result of treatment is osteonecrosis (ON), often occurring in weight bearing joints. Uncertainty exists in the optimal treatment of this cohort of patients. In this review, we describe the etiology and suspected pathogenesis of ON, as well as treatment options described in the literature.

Familial Thrombophilia Is Associated With Primary Multifocal Osteonecrosis: A Case-Control Study of 40 Patients

To characterize pathoetiologic associations of heritable thrombophilia-hypofibrinolysis with idiopathic (primary) multifocal osteonecrosis (ON) (≥3 ON anatomic sites), we prospectively studied 28 women and 12 men with primary multifocal ON compared with 27 women and 24 men with primary nonmultifocal ON (<3 sites) and 110 healthy controls without ON. The 40 cases with primary multifocal ON differed from controls for 3 familial thrombophilias: Factor V Leiden heterozygosity (6 of 40 [15%] vs 2 of 109 [2%], P=.002), G20210A prothrombin gene heterozygosity (6 of 40 [15%] vs 3 of 110 [3%], P=.011), and high (>150%) Factor VIII (8 of 40 [20%] vs 7 of 103 [7%], P=.031). These case-control familial coagulation differences paralleled those in 51 concurrently evaluated cases with primary nonmulti-focal ON, 7 of 51 (14%) of whom had Factor V Leiden heterozygosity vs 2% of controls (P=.005) and 14 of 44 (32%) of whom had high Factor VIII vs 7 of 103 (7%) of controls (P=.0002). Recognition of familial thrombophilia as a common pathoetiology of primary multifocal ON provides an opportunity for early anticoagulation (before joint collapse), allowing both prophylaxis and therapy aimed at relieving pain and slowing or stopping progression of the disease to joint collapse. [Orthopedics. 202X;XX(X):xx-xx.].

Porous tantalum implant for treatment of early-stage osteonecrosis of the femoral head: a minimum 5-year follow-up study

BACKGROUND

To evaluate the survival rate of porous tantalum rod implantation in the treatment of osteonecrosis of the femoral head (ONFH), evaluate its clinical effect and imaging results.

METHODS

From January 2008 to December 2013, porous tantalum rod implantation for ONFH was performed in two institutions. Statistical analysis of operation data, including operation time, blood loss and blood transfusion were recorded.

RESULTS

52 hips received complete follow-up, the average follow-up time was 85.7 months (60-132 months). 24 hips turned to THA at the end of follow-up (46.2%), the average time was 44.3 ± 32.8 months, and the average Harris hip score before THA was 57.1 ± 7.6. Cox proportional-hazards model revealed that Association Research Circulation Osseous (ARCO) stage (P = 0.017), bone marrow edema (P = 0.006) and age > 40 years (P = 0.043) were independent risk factors for conversion to THA.

CONCLUSION

ARCO stage, age and bone marrow edema were risk factors for the failure of porous tantalum rod implantation to convert to THA.

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bone pain at leukemia diagnosis and other risk factors for symptomatic osteonecrosis in children with acute lymphoblastic leukemia

BACKGROUND

Osteonecrosis is a major cause of acute and long-lasting complications of acute lymphoblastic leukemia (ALL) therapy in children. Our study aimed to evaluate the prevalence, characteristics, risk factors, and outcome of osteonecrosis in children with ALL.

PROCEDURE

The cohort included 559 children aged 1-20 years diagnosed with ALL between 2003 and 2018 at two tertiary medical centers in Israel and enrolled in two consecutive protocols: ALL-IC BFM 2002 and AIEOP-BFM ALL 2009. Symptomatic osteonecrosis was prospectively captured as an adverse event.

RESULTS

Osteonecrosis occurred in 51 patients (9.1%). Ninety-four percent of the events were graded as moderate or severe (grades 3-4, Ponte di Legno Toxicity Working Group classification) and multiple bone involvement was common. Full resolution of osteonecrosis was documented in only 16% of the children (median follow-up 4.2 years). Stepwise logistic regression identified five risk factors for osteonecrosis, with a high predictive value (AUC = 0.88): older ageat ALL diagnosis, high-risk ALL group, T-cell immunophenotype, female gender, and a novel risk factor: bone pain at the time of leukemia diagnosis. In addition, osteonecrosis was less common among children of Arab ethnicity. Thrombophilia and an elevated age-adjusted body mass index were not confirmed as risk factors for osteonecrosis.

CONCLUSION

Due to the low rates of osteonecrosis resolution and its debilitating long-term impact, the identification of patients at high risk for osteonecrosis is important for their inclusion in further studies evaluating potential therapeutic adjustments.

Surgical management of symptomatic osteonecrosis and utility of core decompression of the femoral head in young people with acute lymphoblastic leukaemia recruited into UKALL 2003

AIMS

Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON.

METHODS

UK treatment centres were contacted to obtain details regarding surgical interventions and long-term outcomes for patients who were treated for ALL and who developed ON in UKALL 2003 (the national leukaemia study which recruited patients aged 1 to 24 years at diagnosis of ALL between 2003 and 2011). Imaging of patients with ON affecting the femoral head was requested and was used to score all lesions, with subsequent imaging used to determine the final grade. Kaplan-Meier failure time plots were used to compare the use of CD with non surgical management.

RESULTS

Detailed information was received for 85 patients who had developed ON during the course of their ALL treatment. A total of 206 joints were affected by ON. Of all joints affected by ON, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by ON. The majority of the hips were grade 4 or 5 at initial diagnosis of ON. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint-preserving surgical intervention.

CONCLUSION

There is a high incidence of surgery in young people who have received treatment for ALL and who have developed ON. Our results suggest that CD of the femoral head in this group of patients does not delay or improve the rates of femoral head survival. Cite this article: Bone Joint J 2021;103-B(3):589-596.

Inflammation, Bone Healing and Osteonecrosis: From Bedside to Bench

Osteonecrosis of the epiphyseal and metaphyseal regions of major weight-bearing bones of the extremities is a condition that is associated with local death of bone cells and marrow in the afflicted compartment. Chronic inflammation is a prominent feature of osteonecrosis. If the persistent inflammation is not resolved, this process will result in progressive collapse and subsequent degenerative arthritis. In the pre-collapse stage of osteonecrosis, attempt at joint preservation rather than joint replacement in this younger population with osteonecrosis is a major clinical objective. In this regard, core decompression, with/without local injection of bone marrow aspirate concentrate (BMAC), is an accepted and evidence-based method to help arrest the progression and improve the outcome of early-stage osteonecrosis. However, some patients do not respond favorably to this treatment. Thus, it is prudent to consider strategies to mitigate chronic inflammation concurrent with addressing the deficiencies in osteogenesis and vasculogenesis in order to save the affected joint. Interestingly, the processes of inflammation, osteonecrosis, and bone healing are highly inter-related. Therefore, modulating the biological processes and crosstalk among cells of the innate immune system, the mesenchymal stem cell-osteoblast lineage and others are important to providing the local microenvironment for resolution of inflammation and subsequent repair. This review summarizes the clinical and biologic principles associated with osteonecrosis and provides potential cutting-end strategies for modulating chronic inflammation and facilitating osteogenesis and vasculogenesis using local interventions. Although these studies are still in the preclinical stages, it is hoped that safe, efficacious, and cost-effective interventions will be developed to save the host’s natural joint.

Predictive value of magnetic resonance imaging for multifocal osteonecrosis screening associated with glucocorticoid therapy

Objectives: The goals of this study were to elucidate the distribution of multifocal osteonecrosis associated with glucocorticoid therapy using magnetic resonance imaging (MRI) and to establish a MRI screening method.Methods: Between 1986 and 2018, 107 patients underwent MRI screening of their hips, knees, shoulders and ankle joints (856 joints in total) after systemic glucocorticoid therapy.Results: Osteonecrosis was observed in hip (68%), knee (44%), ankle (17%) and shoulder (15%) joints. Patients with bilateral osteonecrosis in their hips were likely to have bilateral osteonecrosis in their knees, whereas patients without osteonecrosis in both hips were unlikely to have osteonecrosis in both knees (p = .0299). Osteonecrosis was never evident in the ankle or shoulder joints when a patient did not have osteonecrosis in both hip and knee joints.Conclusion: In this study, MRI - as a screening method for multifocal osteonecrosis associated with glucocorticoid therapy - showed the sites affected first are hips and knees followed by ankles and shoulders. If osteonecrosis is absent in hip and knee joints, further screening of the ankles and shoulders is unnecessary. Any osteonecrosis observed in the hip and/or the knee joints warrants a second MRI screening of the ankles and shoulders.

British OsteoNEcrosis Study (BONES) protocol: a prospective cohort study to examine the natural history of osteonecrosis in older children, teenagers and young adults with acute lymphoblastic leukaemia and lymphoblastic lymphoma

INTRODUCTION

Osteonecrosis is a well-recognised treatment-related morbidity risk in patients diagnosed with acute lymphoblastic leukaemia (ALL) and lymphoblastic lymphoma (LBL), with a high rate of affected patients requiring surgical intervention. Patients may have asymptomatic changes on imaging studies that spontaneously regress, and little is known about the natural history of osteonecrotic changes seen. The main aim of the British OsteoNEcrosis Study (BONES) is to determine the incidence of symptomatic and asymptomatic osteonecrosis in the lower extremities of survivors of ALL or LBL diagnosed aged 10-24 years in the UK at different time points in their treatment. This study also aims to identify risk factors for progression and the development of symptomatic osteonecrosis in this population, as well as specific radiological features that predict for progression or regression in those with asymptomatic osteonecrosis METHODS AND ANALYSIS: BONES is a prospective, longitudinal cohort study based at principal treatment centres around the UK. Participants are patients aged 10-24 years diagnosed with ALL or LBL under standard criteria. Assessment for osteonecrosis will be within 4 weeks of diagnosis, at the end of delayed intensification and 1, 2 and 3 years after the start of maintenance therapy. Assessment will consist of MRI scans of the lower limbs and physiotherapy assessment. Clinical and biochemical data will be collected at each of the time points. Bone mineral density data and vertebral fracture assessment using dual-energy X-ray absorptiometry will be collected at diagnosis and annually for 3 years after diagnosis of malignancy.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the Yorkshire and Humber Sheffield Research Ethics Committee (reference number: 16/YH/0206). Study results will be published on the study website, in peer-reviewed journals and presented at relevant conferences and via social media.

TRIAL REGISTRATION NUMBER

NCT02598401; Pre-results.

Clinical characteristics and role of whole-body bone scan in multifocal osteonecrosis

Background

Multifocal osteonecrosis (ON) is defined as ON involving three or more distinct anatomical sites. We investigated the clinical characteristics and utility of whole-body bone scans (WBBS) in patients with multifocal ON.

Methods

A total of 254 patients with ON confirmed by magnetic resonance imaging (MRI) or X-rays of the hips or other anatomic regions were evaluated using WBBS and divided into those with multifocal disease and those with oligofocal disease; their clinical characteristics were then compared. All data were analyzed retrospectively both visually and quantitatively (via uptake grading and defect scoring). Associations between the MRI Association Research Circulation Osseous (ARCO) classification and bone scan photon defects and uptake grade were assessed. Factors associated with multifocal ON were identified using logistic regression.

Results

Of the 254 ON patients, 26 (10.2%) had multifocal ON. Their mean age (42.8 ± 14.3 years) was less than that of patients with oligofocal ON (50.9 ± 15.4 years; p = 0.011). Comorbidities, corticosteroid use, and treatment with immunosuppressive agents were more frequent in patients with multifocal ON. Age (odds ratio [OR] = 0.964, p = 0.013), the presence of a comorbidity (OR = 3.387, p = 0.006), present corticosteroid use (OR = 5.696, p < 0.001), and treatment with immunosuppressive agents (OR = 3.447, p = 0.004) were significantly associated with multifocal ON. The MRI ARCO classification was not associated with photon defects in the bone scans of those with femoral ON. However, the ARCO classification was significantly associated with uptake grade.

Conclusions

WBBS may be an additional tool for evaluating ON patients with risk factors for multiple ON, such as younger age, corticosteroid use, and comorbidities.

Avascular necrosis of the femoral head in patients treated for leukaemia. Assessment of the need for a diagnostic protocol

OBJECTIVE

To evaluate the incidence of avascular necrosis of the hip in leukaemia patients treated in our hospital with high doses of corticosteroids in order to evaluate the necessity for an early detection protocol.

MATERIAL AND METHODS

Observational-descriptive and retrospective study from 2005 to 2016 of 253 patients diagnosed with paediatric leukaemia. Patients with musculoskeletal pathology were identified and patients with avascular necrosis were analysed.

RESULTS

A total of 26 patients (10%) had musculoskeletal symptoms. Three patients with avascular necrosis (1.2%) were analysed. One girl, 7 years old, was treated conservatively with traction - suspension and discharge. Two boys, an 11 and a 15.4 year-old,who developed graft-versus-host disease secondary to bone marrow transplantation, and whose treatment included high doses of corticosteroids, developed avascular necrosis of the hip. One was treated with bisphosphonates and forage and the other ended up with a total hip arthroplasty.

DISCUSSION

The occurrence of musculoskeletal symptoms during the treatment of leukaemia is different according to the bibliographic series (0.43 -12.6%). Some authors observe an increased risk in female patients between the ages of 10 and 17. A retrospective study reveals that there is a delay of 3.9 months in the diagnosis of CAP since the onset of pain. Other authors relate NAV to loading joints, age and high doses of corticosteroids.

CONCLUSION

Based on the low incidence of avascular necrosis of the hip in our 14-year-old population treated for leukaemia, the creation of diagnostic protocols seems not to be necessary. However, close monitoring of patients with potential risk factors recognized in the literature, is advisable.

Multifocal osteonecrosis secondary to occupational exposure to aluminum

Multifocal osteonecrosis is a rare disease; chronic use of corticosteroids is considered the main risk factor. Patients with chronic renal failure can develop aluminum toxicity, which can lead to osteomalacia and encephalopathy. An association between osteonecrosis and aluminum toxicity has been reported among patients with dialytic renal insufficiency. Occupational exposure to aluminum rarely causes lung disease and no cases of bone lesions resulting from exposure to this metal have been reported. In this manuscript, we describe a novel case of a patient with multifocal osteonecrosis associated with chronic occupational exposure to aluminum. Level of Evidence IV, Case Report.

Glucocorticoid suppression of osteocyte perilacunar remodeling is associated with subchondral bone degeneration in osteonecrosis

Through a process called perilacunar remodeling, bone-embedded osteocytes dynamically resorb and replace the surrounding perilacunar bone matrix to maintain mineral homeostasis. The vital canalicular networks required for osteocyte nourishment and communication, as well as the exquisitely organized bone extracellular matrix, also depend upon perilacunar remodeling. Nonetheless, many questions remain about the regulation of perilacunar remodeling and its role in skeletal disease. Here, we find that suppression of osteocyte-driven perilacunar remodeling, a fundamental cellular mechanism, plays a critical role in the glucocorticoid-induced osteonecrosis. In glucocorticoid-treated mice, we find that glucocorticoids coordinately suppress expression of several proteases required for perilacunar remodeling while causing degeneration of the osteocyte lacunocanalicular network, collagen disorganization, and matrix hypermineralization; all of which are apparent in human osteonecrotic lesions. Thus, osteocyte-mediated perilacunar remodeling maintains bone homeostasis, is dysregulated in skeletal disease, and may represent an attractive therapeutic target for the treatment of osteonecrosis.

The pathogenesis of multifocal osteonecrosis

Our objective was to study the incidence, etiology, and diagnosis of multifocal osteonecrosis (MFON) and its treatment options to facilitate an earlier diagnosis and to optimize treatment. A radiological investigation was performed in osteonecrosis patients with a high risk of MFON for a more accurate diagnosis between January 2010 and June 2015. For patients with osteonecrosis of both the hip and knee joints or for patients with a history of corticosteroid use or alcohol abuse who had osteonecrosis of one or more joints in the shoulder, ankle, wrist or elbow, magnetic resonance imaging (MRI) was also performed on other joints, regardless of whether these joints were symptomatic. Furthermore, we performed a radiological screening of 102 patients who had a negative diagnosis of MFON but were at a high risk; among them, another 31 MFON cases were successfully identified (30.4%). Thus, the incidence of MFON during the study period increased from 3.1% to 5.2%. Patients diagnosed with osteonecrosis and who are at a high risk of MFON should have their other joints radiologically examined when necessary. This will reduce missed diagnosis of MFON and facilitate an earlier diagnosis and treatment to achieve an optimal outcome.

Clinical and basic research on steroid-induced osteonecrosis of the femoral head in Japan

BACKGROUND

Steroid (glucocorticoid)-induced osteonecrosis of the femoral head (ONFH) in young adults has been a challenging disorder due to frequent incidence of collapse of the femoral head and resulting dysfunction of the hip joint and impairing quality of life. In Japan, the working group on ONFH in the Specific Disease Investigation Committee under auspices of the Japanese Ministry of Health, Labor and Welfare was founded in 1975, clinical and related basic research on ONFH have been continued for more than 40 years.

EPIDEMIOLOGY AND CLINICAL COURSE

A national epidemiologic survey in 2004 estimated that 2200 new patients per year would be diagnosed with ONFH in Japan. ONFH was associated with steroid intake (51%), heavy alcohol intake (31%), both (3%), and neither (15%). The male-to-female ratio was 5:4, and the peak decades of age at definitive diagnosis were the 40s in male patients and the 30s in females. MRI studies revealed that ONFH would have occurred in early phase after start of steroid administration and no expansion of necrotic lesion within the femoral head in spite of continued steroid use. To standardize ONFH diagnosis and treatment strategy, the Committee established validated diagnostic criteria, a radiological staging system, and type categorization.

TREATMENT OPTIONS

Most symptomatic patients with collapse of the femoral head require various surgical procedures. Joint preserving surgery, such as transtrochanteric rotational osteotomy and curved varus osteotomy, should be the treatment choice for young patients with healthy areas without severe collapse of the femoral head.

CLINICAL AND RELATED BASIC RESEARCH

Clinical and basic research has been performed to determine the pathogenesis of steroid-induced ONFH. Low hepatic CYP3A activity has been reported to significantly contribute to the risk of steroid-induced ONFH. Several gene polymorphisms related to steroid metabolism were shown to be associated with the occurrence of ONFH.

Porous Tantalum Implant in Treating Osteonecrosis of the Femoral Head: Still a Viable Option?

The purpose of this study is to evaluate the survivorship and risk factors for radiographic progression and conversion to total hip arthroplasty (THA) after porous tantalum implant surgery in the treatment of osteonecrosis of the femoral head (ONFH). The study comprised 90 ONFH patients (104 consecutive hips) who were treated with a porous tantalum implant combined with bone grafting between June 2008 and December 2013. The patients were 19–61 years of age (mean age, 38 years). The mean follow-up was 42 months. The outcome measures included Harris hip score (HHS), radiographic outcome measures, and survivorship analysis with conversion to THA as the endpoint. The mean postoperative HHS was significantly lower than the mean preoperative HHS (P < 0.001). The Cox proportional hazards model showed that age and Association Research Circulation Osseous (ARCO) stage were independent risk factors for conversion to THA, while age, China-Japan Friendship Hospital (CJFH) type, and ARCO stage were independent risk factors for radiological progression. Ultimately, only 52.9% hips survived. Porous tantalum implant surgery combined with bone grafting is not a viable option for treating ONFH, especially in patients >35 years of age with preoperative ARCO stage III and CJFH type L3.

Multifocal osteonecrosis related to corticosteroid: ten years later, risk of progression and observation of subsequent new osteonecroses

PURPOSE

No study has reported the risk of other site osteonecroses after the diagnosis of multifocal osteonecrosis related to corticosteroids in patients who continue this corticosteroid treatment. An analysis of the time-course to other sites of osteonecrosis, as well as the effects of underlying corticosteroid risk factor on the evolution of asymptomatic lesions at the time of diagnosis, is presented.

METHODS

Two hundred patients were followed prospectively every year during a minimum ten years with a radiograph if a joint became symptomatic. In absence of evidence of osteonecrosis on radiographs of a symptomatic or non-symptomatic joint (hips, shoulders, knees, ankles), patients had an MRI performed at the most recent follow up. The average duration of follow-up after inclusion of the patient in the study was 15 years (range 10-20).

RESULTS

Of the 200 patients followed for an average of 15 years (minimum 10 years, maximum 20 years), 35 patients developed new osteonecrosis lesions during the period of study. Asymptomatic lesions became symptomatic and a high number of collapse was observed resulting in 258 arthroplasties (187 hips, 51 shoulders, 20 knees) at the most recent follow up.

CONCLUSION

The continuation of peak doses (>200 mg) of corticosteroids predicted (p = 0.04) occurrence of new lesions and the continuation of corticosteroids without peak dose was a risk for quicker progression to collapse.

Multifocal Osteonecrosis Secondary to Chronic Alcohol Ingestion

Multifocal osteonecrosis is a relatively rare disorder with an estimated incidence of around 3% among patients diagnosed as having osteonecrosis. Multifocal osteonecrosis is caused by the several conditions including corticosteroid treatment, coagulation disorders, connective tissue disorders including systemic lupus erythematosus (SLE), inflammatory bowel disease, renal transplantation, and underlying malignancies. Alcohol abuse is one of the risk factors for osteonecrosis, and alcohol-induced osteonecrosis is 5% among all the osteonecrosis. Furthermore, the overall incidence of alcohol-induced multifocal osteonecrosis was approximately 6% among all the osteonecrosis induced by the alcohol. Therefore, here, we report an extremely rare case of alcohol-induced multifocal osteonecrosis involving three joints (two knees and one hip) and review the related literature.

Fast sequences MR imaging at the investigation of painful skeletal sites in patients with hip osteonecrosis

BACKGROUND

Multiple osteonecrotic foci can be clinically silent when located in metaphyses and becomes painful when it affects juxta-articular areas. The purpose of this study was to assess the value of fast MR imaging to depict the underlying pathology in cases with skeletal pain other than the already diagnosed hip osteonecrosis.

METHODS/DESIGN

Between 2008 and 2013, 49 patients with already diagnosed hip osteonecrosis reported symptoms of deep skeletal pain in an anatomical site different from the affected hip joint. All patients after thorough history & clinical examination underwent evaluation with x-rays and a single fat suppressed sequence with MR Imaging applying either T2-w TSE or STIR-TSE at the painful site. False positive and false negative findings were recorded for the conventional x-rays and compared to MRI.

DISCUSSION

Forty four (89.8%) patients were positive for osteonecrotic lesions in this study and 76 symptomatic osteonecrosis lesions were revealed at 14 distinct anatomic sites. The agreement between the x-ray findings and the MR imaging regarding osteonecrosis was 46.9%. Plain x-rays showed 43.4% sensitivity, 100% specificity, 100% positive predictive value and 10.4% negative predictive value. Fast MR imaging with fat suppressed sequences is necessary and adequate as a single method for the investigation of painful skeletal sites in patients with already diagnosed hip osteonecrosis. It allows early diagnosis of the potentially debilitating multiple juxta-articular lesions and consequently their prompt management.

High prevalence of prothrombotic abnormalities in multifocal osteonecrosis: description of a series and review of the literature

Multifocal or multiple osteonecrosis (ON), defined by the involvement of 3 or more anatomic sites, is unusual, being observed in only 3%-10% of patients diagnosed with ON. We report the clinical characteristics of a cohort of 29 patients with multifocal ON from a single center and evaluate the prevalence of associated prothrombotic abnormalities in 26 of these patients. We conducted a retrospective study of all patients diagnosed with multifocal ON evaluated in our institution during the last 20 years. We recorded clinical manifestations and underlying diagnoses. A wide thrombophilic profile was performed, including antithrombin, protein C, protein S, lupus anticoagulant, anticardiolipin antibodies, activated protein C resistance, factor V Leiden, mutation G-20210-A of the prothrombin gene, and factor VIII. Coagulation test results were compared with those in a healthy control group and a group of patients with history of lower-extremity deep venous thrombosis. The mean age of the patients was 49.2 ± 15 years (range, 28-81 yr). The mean number of ON localizations per patient was 5.2 ± 2.3 (range, 3-11). Hips were the most commonly affected joint (82%), followed by knees (58%), shoulders (37%), and ankles (13%). Most patients had an underlying disease process, and 12 of 25 (48%) patients had coagulation test abnormalities. The most common alterations were high factor VIII levels and antiphospholipid antibody (aPL) positivity in 24% and 20% of cases, respectively. These abnormalities were more prevalent in patients with multifocal ON compared with patients in the control groups. Sixty-one percent of patients had a history of corticosteroid treatment. Patients with coagulation abnormalities had a higher number of ON localizations per patient (6.5 ± 2.7 vs. 3.88 ± 0.8; p = 0.002) and a higher prevalence of atypical ON localizations (25% vs. 0%; p = 0.05). In conclusion, in the present cohort of patients with multifocal ON, 48% of the patients had at least 1 prothrombotic factor, especially high levels of factor VIII and aPL. These findings have major implications for the diagnosis and treatment of multifocal ON and clearly indicate the need to perform a thrombophilic profile in these patients.

Osteonecrosis of the femoral head extending into the femoral neck

Osteonecrosis of the femoral head (ONFH) is an ischemic disorder that can lead to femoral head collapse and secondary osteoarthritis. Although the condition is usually limited to the femoral head, we report a rare case of biopsy-proven ONFH extending into the femoral neck, which required hip replacement surgery. We emphasize the imaging features of this condition and briefly discuss its potential relevance.

Glucocorticoid-induced avascular bone necrosis: diagnosis and management

Glucocorticoid use is one of the most important causes of avascular bone necrosis (AVN). The pathogenesis of glucocorticoid-induced AVN is not fully understood but postulated mechanisms include fat hypertrophy, fat emboli and intravascular coagulation that cause impedance of blood supply to the bones. Data regarding the relationship between AVN and dosage, route of administration and treatment duration of glucocorticoids are conflicting, with some studies demonstrating the cumulative dose of glucocorticoid being the most important determining factor. Early recognition of this complication is essential as the prognosis is affected by the stage of the disease. Currently, there is no consensus on whether universal screening of asymptomatic AVN should be performed for long-term glucocorticoid users. A high index of suspicion should be exhibited for bone and joint pain at typical sites. Magnetic resonance imaging (MRI) or bone scintigraphy is more sensitive than plain radiograph for diagnosing early-stage AVN. Conservative management of AVN includes rest and reduction of weight bearing. Minimization of glucocorticoid dose or a complete withdrawal of the drug should be considered if the underlying conditions allow. The efficacy of bisphosphonates in reducing the rate of collapse of femoral head in AVN is controversial. Surgical therapy of AVN includes core decompression, osteotomy, bone grafting and joint replacement. Recent advances in the treatment of AVN include the use of tantalum rod and the development of more wear resistant bearing surface in hip arthroplasty.

Atraumatic osteonecrosis of the distal radius and ulna: case series and review

PURPOSE

Atraumatic multifocal osteonecrosis is defined as the occurrence of atraumatic osteonecrosis in 3 or more anatomic locations, and it is rare. We identified 6 patients with osteonecrotic lesions in the distal ulna, radius, or both. The purposes of this study were to describe the clinical manifestations of atraumatic multifocal osteonecrosis affecting these bones, to identify risk factors for developing the disease in these locations, and to evaluate the success of treatment by percutaneous drilling.

METHODS

A total of 10 wrists in 6 women with a mean age of 41 years had symptomatic osteonecrosis. Patients were treated by percutaneous drilling after they had failed nonoperative modalities. Clinical evaluation included preoperative and postoperative Michigan Hand Questionnaire scores plain radiographs, and MRI evaluations were performed to characterize the disease. The incidence of risk factors was recorded.

RESULTS

There was disease occurrence in the radius in all 10 wrists and in the ulnas of 4 wrists. All patients presented with symptomatic osteonecrosis of the large joints (primarily knee or hip), presumably secondary to corticosteroid use. These patients later developed symptomatic pain in the distal ulna, radius, or both that impaired daily activities. Other risk factors included alcohol or tobacco use, blood dyscrasias, and systemic lupus erythematosus. Treatment consisted of percutaneous drilling of the distal radius (and ulna when affected). One patient required additional bilateral drillings and had further improvement in her Michigan Hand Questionnaire scores. At a mean follow up of 35 months, there was no disease progression as evident radiographically.

CONCLUSIONS

The distal radius and ulna are rare sites of osteonecrosis associated with multifocal disease. The clinical presentation and risk factors are similar to osteonecrosis in the large joints. Magnetic resonance imaging identifies necrotic lesions. The present study suggests that disease in these sites can be safely and effectively treated with percutaneous drilling.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Multifocal joint osteonecrosis in sickle cell disease

The purpose of this study was to evaluate the frequency of multifocal osteonecrosis in patients with sickle cell disease. Between 1980 and 1989, 200 patients with sickle cell disease were treated in our institution for osteonecrosis. The patient population consisted of 102 males and 88 females with a mean age of twenty-six years at the time of presentation (range, eighteen to thirty-five years) and was followed until the year 2005. This cohort of patients was follow-up during average 15 years (until the year 2005). Multifocal osteonecrosis was defined as a disease of 3 or more anatomic sites. At the time of presentation, 49 patients were identified as having multifocal osteonecrosis. At the most recent follow-up, 87 patients had multifocal osteonecrosis. So at the last follow up among these eighty-seven patients, the occurrence of osteonecrosis was 158 lesions of the proximal femur associated with 151 proximal humerus osteonecroses, thirty-three lateral femoral condyle osteonecroses, twenty-eight distal femoral metaphysis osteonecroses, twenty-seven medial femoral condyle osteonecroses, twenty-three tibial plateau osteonecroses, twenty-one upper tibial metaphysis osteonecroses and forteen ankle osteonecroses. The total number of osteonecrosis was 455 in these 87 patients. The epiphyseal lesions were more frequent than the metadiaphyseal lesions excepted in the proximal tibia (Table 3). In conclusion, in patients with sickle cell disease, the risk of multifocal osteonecrosis is very high. In patients with hip osteonecrosis, the other joints should be evaluated with radiograph and MRI if the joint is symptomatic. In patients with osteonecrosis of the knee, shoulder or ankle, the patients' hip should be evaluated by radiographs or MRI, regardless of whether the hip is symptomatic.

Osteonecrosis in kidney recipients: has hypocalcaemia a role?

In a previous study, the musculoskeletal affections among kidney recipients (KR) were reported, with 63 KR suffering from joint affections. We sought to determine the prevalence of osteonecrosis (ON) among those KR with joint affections, its distribution among the affected joints, and possible risk predictors. KR were subjected to biochemical, haematological, and hepatitis serology estimations. Radiographic and magnetic resonance imaging were performed. Relevant data were retrieved from Patient Information System. Fourteen KR were suffering from ON, with an incidence of 22.2% in KR with joint affections and 12.0% in the target population of KR. The femoral head was affected in 57.1% and the femoral condyles in 28.6%. Hypocalcaemia was observed in KR with ON. Whether hypocalcaemia is a causative or associative of ON yet remains to be decided in forthcoming studies.

Steroid-induced osteonecrosis: the number of lesions is related to the dosage

Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003. We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone.

Alcohol-induced multifocal osteonecrosis: a case report with 14-year follow-up

Alcohol-induced osteonecrosis of femoral head is common but multifocal osteonecrosis secondary to alcohol is very rare. The authors report one case of multifocal alcohol-induced osteonecrosis involving both hips and both knees and its subsequent progression and management over a period of 14 years. There was bilateral involvement of hips in pre-collapse stage for which a core decompression was done. The left hip responded well and at 14-year follow-up was asymptomatic with full range of motion. The core decompression surgery failed in the right hip within 1 year and subsequently hybrid total hip replacement arthroplasty was done with good functional results at 13 years follow-up. The diagnosis of knee osteonecrosis was most probably missed initially and was subsequently diagnosed 6 months back due to symptoms of pain and radiographic findings for which a core decompression was done with good early results. The results of treatment of hip was excellent in our patient and despite the rarity, a high degree of suspicion and regular screening is necessary to detect involvement of other areas like the knee in alcohol-induced osteonecrosis.

Thrombophilia, hypofibrinolysis, the eNOS T-786C polymorphism, and multifocal osteonecrosis

BACKGROUND

We examined the hypothesis that thrombophilia, hypofibrinolysis, and the endothelial nitric oxide synthase (eNOS) T-786C polymorphism are common, potentially treatable, and similar pathophysiologic causes of multifocal (three sites or more) and unifocal (single-site) osteonecrosis.

METHODS

We prospectively evaluated twenty-six consecutively referred adults with multifocal osteonecrosis, who included thirteen with idiopathic multifocal osteonecrosis and thirteen with secondary multifocal osteonecrosis (resulting from steroid therapy in ten and alcoholism in three). We compared these patients with race, sex, and age-matched normal control subjects and with patients with idiopathic unifocal and secondary unifocal osteonecrosis, respectively. Using polymerase chain reaction and serologic measures, we studied thrombophilic and hypofibrinolytic mutations and the eNOS T-786C polymorphism.

RESULTS

The total number of polymerase chain reaction and serologic thrombophilic-hypofibrinolytic abnormalities and the eNOS T-786C polymorphism did not differ between patients with idiopathic (p > 0.5) or secondary (p > 0.5) multifocal and unifocal osteonecrosis. The frequency of low free protein-S levels (<66%) in patients with secondary multifocal osteonecrosis (four of eleven patients) was higher than that in the control subjects (one of fifty-nine) (risk ratio = 21.5; 95% confidence interval, 2.6 to 174; p = 0.0016, Benjamini-Hochberg adjusted p [Bp] = 0.004). Factor-V Leiden heterozygosity was present in two of thirteen patients with secondary multifocal osteonecrosis compared with none of sixty-four control subjects (p = 0.027, Bp = 0.008). For eleven patients with secondary multifocal osteonecrosis, the eNOS T-786C polymorphism was present in nine of twenty-two alleles compared with eight of forty-four alleles in twenty-two normal control subjects (risk ratio = 2.3; 95% confidence interval, 1.0 to 5.0; p = 0.047, Bp = 0.016). The frequency of homocystinemia (>13.5 mumol/L) was higher in patients with idiopathic multifocal osteonecrosis (two of thirteen patients) than in normal controls (none of fifty-one) (p = 0.039, Bp = 0.004). A high level of factor VIII (>150%) was seen in four of eight patients with idiopathic multifocal osteonecrosis and in seven of forty-eight normal controls (risk ratio = 3.4; 95% confidence interval, 1.3 to 9.1; p = 0.04, Bp = 0.008). The eNOS T-786C mutant allele was present in seven of twelve alleles in the six patients with idiopathic multifocal osteonecrosis who were tested, compared with twenty-five of 108 alleles in fifty-four control subjects (risk ratio = 2.5; 95% confidence interval, 1.4 to 4.5; p = 0.015, Bp = 0.008).

CONCLUSIONS

Limited by the small numbers of patients with multifocal osteonecrosis, this exploratory study suggested that thrombophilia was associated with both idiopathic multifocal osteonecrosis and secondary multifocal osteonecrosis, as was the eNOS T-786C polymorphism. Multifocal and unifocal osteonecrosis are similarly associated with thrombophilia, hypofibrinolysis, and the eNOS T-786C polymorphism, which are potentially treatable pathophysiologic conditions, requiring further study.

On a case of multifocal osteonecrosis in a patient suffering from acute lymphoblastic leukemia

The Authors describe the case of a 14-year-old girl who developed a multifocal osteonecrosis (ON), after treatment with chemotherapy and corticosteroids for acute lymphoblastic leukemia (ALL). She came to our attention about 6 months after the beginning of treatment complaining of pain in her left knee and later in both hips and shoulders. Radiography and MRI confirmed the presence of avascular ON at all these sites. The patient underwent bilateral total hip arthroplasty, which was still functioning well at the last follow-up visits at 5 years, and at 5 years and 4 months. ON is increasingly recognized as a complication of the treatment of cancer in children and adolescents, and as patients now frequently survive ALL into adulthood, orthopedists will be increasingly called on to manage this complication affecting multiple joints in children and young adults.

Osteonecrosis in children and adolescents with cancer

Osteonecrosis is recognized increasingly as a complication of the treatment of cancer in young people, especially those with acute lymphoblastic leukemia and non-Hodgkin lymphoma, reflecting a probable pathogenetic role of steroid therapy. Children >/=10 years of age and Whites are at particular risk, and genetic predispositions have been identified. The disorder affects weight-bearing joints predominantly. It is commonly bilateral and multi-articular. Treatment options include both surgical and non-surgical interventions.

Osteonecrosis in children and adolescents with cancer - an adverse effect of systemic therapy

Osteonecrosis (ON) is recognised increasingly as a complication of the treatment of cancer in children and adolescents. It is especially prevalent among survivors of acute lymphoblastic leukaemia and non-Hodgkin lymphoma, in whom as many as 1/3 may be affected, likely reflecting the cumulative exposure to glucocorticosteroid therapy. The pathogenesis is complex and includes suppression of bone formation, expansion of the intra-medullary lipocyte compartment and a direct effect on nutrient arteries. Children > or =10 years of age are at particular risk and the disorder is substantially more common in Whites than in Blacks. Genetic predispositions have been identified. ON is often multi-articular and bilateral, affecting weight-bearing joints predominantly. Surgical management options are of concern in young growing subjects, although injection of autologous marrow into affected sites offers promising results. Other novel approaches include the use of anti-resorptive drugs and strategies for prevention, such as with lipid-lowering agents, are being explored.

Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee

BACKGROUND

The reported outcomes of patients who underwent total or unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee are often from studies that lack the number of subjects necessary to generate meaningful conclusions. We systematically reviewed the available literature in order to define the outcomes of patients after total knee arthroplasty for secondary osteonecrosis and after total or unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee.

METHODS

A literature review yielded twenty cohorts with demographic patient information and outcome scores (global knee scores, radiographic outcomes, and revision rates) for patients who had knee arthroplasty as treatment for either secondary or spontaneous osteonecrosis of the knee. The mean preoperative and postoperative global knee scores, the mean revision rate, and the categorization of the mean "poor" and mean "good" outcomes for the knees with each underlying disease were tabulated and reported. The demographic data and the reported mean global knee scores were weighted by the number of knees in each study.

RESULTS

Total knee arthroplasty was performed in 150 knees with secondary osteonecrosis and 148 knees with spontaneous osteonecrosis, and unicompartmental knee arthroplasty was performed in sixty-four knees with spontaneous osteonecrosis. Total knee arthroplasty for spontaneous osteonecrosis of the knee was associated with the best outcomes (higher "good" and postoperative global knee scores and lower revision [3%] and "poor" outcome [6%] rates compared with the other two groups). The outcomes after total knee arthroplasty in knees with secondary osteonecrosis as well as in knees with spontaneous osteonecrosis were better in the cohorts operated on during or after 1985 than in those operated on before 1985. Similarly, the outcomes after unicompartmental knee arthroplasty in knees with spontaneous osteonecrosis of the knee were also better in the cohorts operated on during or after 1985 than in those operated on before 1985.

CONCLUSIONS

Total knee arthroplasty performed as treatment for either secondary osteonecrosis or spontaneous osteonecrosis and unicompartmental knee arthroplasty performed as treatment for spontaneous osteonecrosis were associated with improved outcomes in cohorts with more recent operative dates. The evidence suggests that the use of contemporary cemented implants in total knee arthroplasty and the selective use of stems and augments in patients who have development of secondary osteonecrosis after total knee arthroplasty are producing outcomes that are comparable to those seen after total knee arthroplasty for osteoarthritis. Although the outcomes of patients who have total knee arthroplasty for the treatment of spontaneous osteonecrosis of the knee have historically been favorable, such outcomes have also shown particular improvement in the studies from more recent operative periods. Although poor outcomes were seen after unicompartmental knee arthroplasty in earlier studies of patients with spontaneous osteonecrosis of the knee, it is possible that those results were secondary to inappropriate patient selection, as the authors of the most recent and, to our knowledge, the only study to follow established operative indications regarding the use of unicompartmental knee arthroplasty reported excellent results.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Arthroscopic microfracture treatment for osteonecrosis of the knee

PURPOSE

This study evaluated the results of arthroscopic subchondral microfracture performed on patients with spontaneous osteonecrosis (ON) (group 1) or secondary ON (group 2) of the knee joint.

TYPE OF STUDY

Retrospective clinical study.

METHODS

Group 1 included 26 patients (mean age, 48 years) who had spontaneous ON. Group 2 included 15 patients (mean age, 32 years) with ON secondary to inflammatory disease or steroid therapy. Seventy-six percent of the chondral defects were located in the medial femoral condyle. The average defect sizes in group 1 was 162 mm2 and in group 2 was 362 mm2. After debridement of the necrotic tissues, multiple perforations were placed into the subchondral bone to obtain revascularization.

RESULTS

There was an increase in the average Lysholm scores from 57 to 90 in group 1 after 27 months of mean follow-up (P < .05); 71% of patients could participate in strenuous sports with no or minimal limitation. The mean activity level in group 1 according to Cincinnati Knee Rating System was 6 preoperatively and 13.54 postoperatively. For group 2, the average scores showed significant improvement and patient satisfaction after surgery (preoperative and postoperative average Lysholm scores were 41 and 75, respectively, with mean follow-up of 37 months). Average activity level in group 2 increased from 2.67 to 11.73. Control magnetic resonance imaging scans of the cases revealed the continuity of normal cartilage with cartilage-like tissue in the treated areas. However, an increase of the size of ON in the subchondral bone was detected in 27% of the knees.

CONCLUSIONS

The microfracture technique is safe, simple, and cost-effective, and may be an alternative procedure for treatment of ON of the knee, especially in young patients, before possible subsequent replacement surgery.

LEVEL OF EVIDENCE

Level IV.

Idiopathic osteonecrosis of the medial tibial plateau

Osteonecrosis of the medial tibial plateau is characterized by acute pain on the medial aspect of the knee. Progression can lead to articular collapse and requires early diagnosis and treatment. We studied seven patients affected of idiopathic osteonecrosis of the tibial plateau. The mean age was 62 years and the mean follow-up 42 months. We performed roentgenograms in all patients, bone scans in three patients and magnetic resonance image (MRI) in five. MRI shows T1-weighted low-intensity signal and T2-weighted high-intensity signal with a surrounding area of intermediate low-intensity signal. An increased focal uptake was seen at bone scan. Histological findings showed necrotic bone with empty lacunae. Surgical treatment consisted of tibial subchondral drilling in four patients-two of them by failure of conservative treatment, and a total knee arthroplasty in other two. One patient had a satisfactory evolution with conservative treatment. Idiopathic osteonecrosis of the tibial plateau must be considered in elderly patients with knee pain over the medial tibial plateau. At early stages, decompression with tibial drilling must be considered. This procedure allows a prompt and effective relief of symptoms.

Osteonecrosis: a treatment related toxicity in childhood acute lymphoblastic leukemia (ALL)--experiences from trial ALL-BFM 95

BACKGROUND

Osteonecrosis (ON) as a complication during treatment of acute lymphoblastic leukemia (ALL) has gained rising attention over the past decade. Corticosteroids, representing an essential element of antileukemic therapy, are known to induce ON, which in turn may cause significant morbidity. Due to spontaneous reporting of affected patients with ON, a group-wide evaluation was performed to determine incidence, risk factors, and morbidity for ON.

PROCEDURE

Patients were identified via spontaneous reporting to the study center and via questionnaire, addressing all 64 participating centers. We retrospectively analyzed 1,951 patients below 18 years of age who were treated according to trial ALL-BFM 95 between 01.01.1996 and 30.06.2000.

RESULTS

Thirty-one patients (14 male, 17 female) affected by ON were identified. The overall 5-year cumulative incidence for ON is 1.8%. The incidence for patients <10 years is 0.2%, whereas for patients >/=10 years it is 8.9% (P = 0.00) and 16.7% (P = 0.003) for patients >/=15 years. The majority (n = 20) showed ON in two or more joints, and the joints most commonly affected were knees (14 patients, 24 affected knees) and hips (11 patients, 20 affected joints). Thirteen out of 31 patients had to undergo surgery in the course of their disease.

CONCLUSIONS

Symptomatic ON is a rare event in patients treated with BFM-type chemotherapy with an overall 5-year cumulative incidence of 1.8%. The age group >/=10 years, and particularly adolescents >/=15 years have a significantly higher risk of developing ON.

Inflammatory bowel disease related osteonecrosis: report of a large series with a review of the literature

BACKGROUND

Osteonecrosis is a major complication of inflammatory bowel disease usually associated with steroid use. There are few large series available detailing the specifics of affected patients.

AIM

To identify any specific characteristics of osteonecrosis in this cohort. A major focus was placed on steroid dose, the average time between diagnosis of IBD and appearance of osteonecrosis and the frequency of multiple joint involvement.

METHODS

Our study identified 23 patients in the practices of five gastroenterologists at the Mount Sinai Medical Center. We retrospectively reviewed their clinical history, as well as imaging studies. We classified osteonecrosis according to the Association Research Circulation Osseous (ARCO) staging system.

RESULTS

Although our prednisone dosing data could not be used as an accurate predictor of onset or joint distribution, there was a tendency for correlation between the average daily dosing and the ARCO score. The ARCO scoring system was consistent for patients with bilateral hip involvement. The distribution of affected joints in IBD is similar to other conditions associated with osteonecrosis, with hips being the most frequently involved joints. Data showed bilateral involvement in most hips, but usually unilateral disease in the shoulders and knees. Treatment options include core decompression for early stages, whereas joint replacement surgery is required for stages 3 and 4.

CONCLUSION

IBD predisposes patients to corticosteroid induced osteonecrosis. An exact threshold dose has not been determined. The data suggests that either long term therapy or short term high dose treatment increases the risk of osteonecrosis. Even if symptoms are limited to one joint, multiple joints are often involved and comprehensive testing with MRI is indicated in all cases.

Tacrolimus may be associated with lower osteonecrosis rates after renal transplantation

To compare the effect of two immunosuppressive agents, cyclosporin A and tacrolimus, in terms of the development of osteonecrosis after renal transplantation, a cohort study was done. The cyclosporin A group and the tacrolimus group consisted of 32 patients each, and were matched for age, gender, and renal allograft (cadaveric or living). Four patients with osteonecrosis of the femoral head and one patient with osteonecrosis of the knee were observed in the cyclosporin A group, whereas none of the patients in the tacrolimus group had osteonecrosis. All five patients with osteonecrosis were diagnosed on magnetic resonance imaging within 2 years after renal transplantation, and were followed up for more than 3 years after diagnosis. Significant differences were observed in the number of patients with acute rejection (cyclosporin A, 16 patients versus tacrolimus, seven patients). Significant differences also were found in the dose of pulse corticosteroids at 2 weeks (cyclosporin A, 1161.1 +/- 939.6 mg versus tacrolimus, 674.3 +/- 587.5 mg) and 4 weeks after transplantation (1727.5 +/- 1399.9 mg versus 965.0 +/- 861.9 mg). The risk of osteonecrosis after renal transplantation was reduced in the patients who used tacrolimus for immunosuppression, which reduced the number of acute rejection episodes and the dose of pulse corticosteroid administration.

Iliac bone graft for steroid-associated osteonecrosis of the femoral condyle

The use of steroid medication may predispose to osteonecrosis of the femoral condyle. However, there is a controversy regarding treatment of this disease, especially for lesions in advanced stages. Since 1987, the authors have treated such lesions by autologous osteoperiosteal graft obtained from the iliac bone. When limb alignment was affected by the disease, proximal tibial valgus or varus osteotomy was done concomitantly. The rationale for this method is to replace the necrotic bone and damaged cartilage by autogenous bone and periosteum, anticipating the chondrogenic potential of the latter. In this study, 10 knees in eight patients were reviewed to learn the outcome of this procedure with a mean followup of 79 months (range, 32-158 months). The grafts were incorporated successfully in nine joints, and satisfactory results were achieved in all patients. Therefore autologous iliac bone graft is a promising alternative for treatment of osteonecrosis, especially when patients are young and physically active.

Hypofibrinolysis, lipoprotein(a), and plasminogen activator inhibitor

Parameters of hypofibrinolysis and thrombophilia were assessed in 20 consecutive patients with bone marrow edema sydrome of the hip who lacked typical risk factors for osteonecrosis. Twenty healthy subjects, matched for age and gender, served as the control subjects. In patients with bone marrow edema syndrome, elevated levels of lipoprotein(a) and plasminogen activator inhibitor were found in nine (45%) and two patients (10%), respectively. Elevation of lipoprotein(a) was present in two patients in the control group; however, plasminogen activator inhibitor levels were normal in this group. Mean levels of lipoprotein(a) were 34.8 mg/dL in the patients with bone marrow edema versus 13.8 mg/dL in the control subjects. Mean concentrations of plasminogen activator inhibitor, apolipoproteins, lipid metabolism parameters, and indicators of thrombophilia did not differ in both groups. Pulsed field gel electrophoresis and Southern blots confirmed the presence of pathologic allelotypes in three patients with elevated levels of lipoprotein(a) who had a familial occurrence of bone marrow edema syndrome. These findings also underline a fundamental role of hypofibrinolysis, mediated by elevated levels of lipoprotein(a) or plasminogen activator inhibitor, or both, in the former idiopathically considered etiology of the bone marrow edema syndrome of the hip.

Osteonecrosis of the patella in patients with nontraumatic osteonecrosis of the femoral head: MRI findings in 60 patients

We examined both knees in 60 patients with nontraumatic osteonecrosis of the femoral head with three-dimensional MRI. We found osteonecrosis of the patella in 9 patients (10 knees) and osteonecrosis of the femoral or tibial condyles/metaphyses in 35 patients (61 knees). In the patella, the necrosis was located in the proximal half and tended to develop in patients with other necrotic lesions in the knee.

Atraumatic osteonecrosis of the adult elbow

Osteonecrosis is a disease that leads to joint destruction and often involves large joints, such as the hips, knees, and shoulders. Nontraumatic osteonecrosis of the adult elbow, to the best of the authors' knowledge, has not been reported. Nine adult patients with atraumatic osteonecrosis of 11 elbows were identified. The mean age at presentation was 36 years (range, 26-63 years); five patients were women and four were men. Six elbows involved the capitellum, three involved the lateral epicondyles, one involved the trochlea and radial head, and one involved medial and lateral epicondylar disease. All patients were receiving corticosteroid therapy, and no relationship between the duration or the amount of corticosteroid use and the severity of the osteonecrosis was found. Seven patients with radiographic Stage I and Stage II disease responded well to nonoperative treatments consisting of activity modification, analgesics, and a brief period of immobilization. Nonoperative treatment failed in two patients with Stage III disease, and they had core decompressions for pain relief. One patient with late Stage III disease in both elbows underwent bilateral total elbow arthroplasties. In contrast to the pediatric population, osteonecrosis of the adult elbow potentially can lead to end stage arthritis. If the osteonecrosis is diagnosed early, nonoperative treatment may be effective in relieving pain, although the long-term results of these treatments remain unknown.