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

Plasma SQSTM1/p62 act as a biomarker for steroid-induced osteonecrosis of the femoral head

Autophagy is closely associated with the onset and progression of steroid-induced osteonecrosis of the femoral head (SIONFH). SQSTM1/p62 is an important indicator of autophagic activity. The aim of this study was to investigate the role of SQSTM1/p62 in the development of SIONFH. From May 2021 through November 2021, 36 patients diagnosed with SIONFH and 36 healthy controls were recruited for this study. Evaluations included imaging and pathologic assessment of clinical bone tissue, location and level of SQSTM1/p62 expression, plasma SQSTM1/p62 levels, and receiver operating characteristic (ROC) curves. We observed that the expression level of SQSTM1/p62 in bone samples decreased with the Association Research Circulation Osseous (ARCO) phase. Plasma SQSTM1/p62 levels were significantly higher in the SIONFH group compared to healthy controls. Plasma SQSTM1/p62 levels were higher in pre-crash patients than in post-crash patients, and lower plasma SQSTM1/p62 levels were associated with elevated ARCO stage. Plasma SQSTM1/p62 may represent a potential biomarker for different stages during SIONFH. Lower plasma SQSTM1/p62 levels indicate an advanced stage of SIONFH. This study provides new clues for early diagnosis of SIONFH.

Avascular necrosis of the epiphyses of bones in patients who have had SARS-CoV-2 infection: Clinical observations and a narrative review of literature data

The SARS-CoV-2 coronavirus pandemic is a leading medical problem that is in the focus of attention of representatives of all medical specialties. In addition to fighting the COVID-19 infection itself, the task of preventing and treating a wide range of complications arising after the disease is becoming increasingly urgent. One of these complications is avascular necrosis (AN) of bone tissue – a severe pathology that leads to serious suffering, a decrease in the quality of life and disability of patients. For the period from 2020 to 2022 there are 9 reviews in the world literature devoted to the pathogenesis, clinical features and treatment possibilities of this complication. During the same period, 5 articles were published describing clinical observations of AN after suffering COVID-19.The purpose of this work is to demonstrate our own clinical observations, as well as to review the available literature data on the problem of AN after COVID-19 infection. Based on the analysis, it can be concluded that AN after SARS-CoV-2 infection most often develops in the femoral head (>50% of cases), occurs regardless of the severity of the disease and the cumulative dose of glucocorticoids used in the acute period of the disease. It seems advisable to perform an MRI of the hip joints at least once every 3 months for all patients who have had COVID-19 in severe and moderate form during the first year after convalescence.

Bone Marrow Multipotent Mesenchymal Stromal Cells as Autologous Therapy for Osteonecrosis: Effects of Age and Underlying Causes

Bone marrow (BM) is a reliable source of multipotent mesenchymal stromal cells (MSCs), which have been successfully used for treating osteonecrosis. Considering the functional advantages of BM-MSCs as bone and cartilage reparatory cells and supporting angiogenesis, several donor-related factors are also essential to consider when autologous BM-MSCs are used for such regenerative therapies. Aging is one of several factors contributing to the donor-related variability and found to be associated with a reduction of BM-MSC numbers. However, even within the same age group, other factors affecting MSC quantity and function remain incompletely understood. For patients with osteonecrosis, several underlying factors have been linked to the decrease of the proliferation of BM-MSCs as well as the impairment of their differentiation, migration, angiogenesis-support and immunoregulatory functions. This review discusses the quality and quantity of BM-MSCs in relation to the etiological conditions of osteonecrosis such as sickle cell disease, Gaucher disease, alcohol, corticosteroids, Systemic Lupus Erythematosus, diabetes, chronic renal disease and chemotherapy. A clear understanding of the regenerative potential of BM-MSCs is essential to optimize the cellular therapy of osteonecrosis and other bone damage conditions.

Evidence-Supported HBO Therapy in Femoral Head Necrosis: A Systematic Review and Meta-Analysis

Although many studies have shown that hyperbaric oxygen (HBO) therapy can significantly improve symptoms and quality of life of patients affected by femoral head necrosis, this therapy is not worldwide approved yet. This meta-analysis was performed to evaluate its clinical effect. Relevant studies published before May 2020 were systematically searched using terms related to HBO and femoral head necrosis. Fixed and random-effects models were used to estimate the odds ratio (OR) with 95% confidence intervals (CI). Subgroup analyses and publication bias tests were carried out to explore potential study heterogeneity and bias. Ten studies involving 353 controls and 368 HBO-treated cases were included, most of which were conducted on Asian population. The clinical effect in the HBO therapy group was 3.84 times higher than in the control group (OR = 3.84, 95% CI (2.10, 7.02), p < 0.00001). Subgroup analyses showed that the clinical effect of HBO therapy was statistically significant in the Asian subpopulation which represented most of the subjects (OR = 3.53, 95% CI (1.87, 6.64), p < 0.00001), but not in the non-Asian subpopulation, probably because of insufficient numerosity (OR = 7.41, 95% CI (0.73, 75.71), p = 0.09). The results of this meta-analysis suggest that patients with femoral head necrosis treated with HBO therapy can achieve a significant clinical improvement.

Bone-Specific Drugs and Osteonecrosis of Sites Other Than the Jaw: A Nationwide Cohort Study

Bone-specific drugs (BSDs) increase the risk of osteonecrosis of the jaw (ONJ), but whether they increase the risk of osteonecrosis at other sites is not known. Two studies, a cohort study and a case-control study, were conducted using registry data on everyone who was residing in Sweden on December 31, 2005, and who was 50 years of age or older at the time (n = 3,523,912). In the cohort study, individuals prescribed a BSD during the period 2006-2017 (n = 217,387) were 1:1 matched with nonusers on birth year, sex, hip fracture status, and Swedish or foreign origin. In the case-control study, individuals diagnosed with osteonecrosis during 2006-2017 (n = 12,614) were 1:1 matched with individuals without a diagnosis of osteonecrosis on birth year, sex, and Swedish or foreign background. In the cohort study, osteonecrosis was diagnosed in 983 BSD users and 214 nonusers (adjusted hazard ratio [aHR] 4.02; 95% CI, 3.32-4.87), during a mean treatment time of 2.8 years. A similar association was observed in a subcohort where all individuals diagnosed with cancer (HR 4.82; 95% CI, 2.52-9.22). The greatest difference in incidence between BSD users and nonusers was observed in patients with a femoral neck fracture that was not treated with total hip arthroplasty or hemiarthroplasty (incidence rate difference, 77.8 cases per 10,000 person-years, p < .05). The risk of osteonecrosis was higher in users of denosumab (HR 1.93; 95% CI, 1.33-2.79) and users of zoledronic acid (HR 1.95; 95% CI, 1.31-2.91) than in users of other BSDs. The increased risk of osteonecrosis decreased after the end of therapy (p < .001 for time trend). The results were confirmed in the case-control study. In summary, use of BSDs, especially more potent BSDs, is associated with increased risk of osteonecrosis of sites other than the jaw. This increased risk decreases after the final dose of BSD. © 2020 American Society for Bone and Mineral Research.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update

➢. Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. ➢. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. ➢. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. ➢. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. ➢. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.

Epidemiology of osteonecrosis among older adults in Sweden

This study estimated the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults. Osteonecrosis was approximately 10 times more common than in previous studies. The strongest risk factors were dialysis, hip fracture, osteomyelitis, and organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

INTRODUCTION

The aim of this study was to estimate the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults and in a large number of risk groups in that cohort.

METHODS

In this retrospective cohort study, we included everyone who was aged 50 years or older and who was living in Sweden on 31 December 2005. We used Swedish national databases to collect data about prescription medication use, diagnosed medical conditions, and performed medical and surgical procedures. The study outcome was diagnosis of primary or secondary osteonecrosis at any skeletal site. The strength of risk factors was assessed using age- and sex-standardized incidence ratios (SIRs).

RESULTS

The study cohort comprised 3,338,463 adults. The 10-year risk of osteonecrosis was 0.4% (n = 13,425), and the incidence rate was 4.7 cases/10000 person-years (95% confidence interval [CI], 4.6 to 4.7 cases). The strongest risk factors for osteonecrosis were hip fracture (SIR, 7.98; 95% CI, 7.69-8.27), solid organ transplantation (SIR, 7.14; 95% CI, 5.59-8.99), dialysis (SIR, 6.65; 95% CI, 5.62-7.81), and osteomyelitis (SIR, 6.43; 95% CI, 5.70-7.23). A history of hip fracture was present in 21.7% of cases of osteonecrosis, but osteomyelitis, dialysis, and solid organ transplantation were present in only 0.5 to 2% of cases.

CONCLUSIONS

Osteonecrosis was approximately 10 times more common than a small number of previous population-based studies have suggested. The strongest risk factors for osteonecrosis were dialysis, hip fracture, osteomyelitis, and solid organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

Delay of total hip arthroplasty to advanced stage worsens post-operative hip motion in patients with femoral head osteonecrosis

PURPOSE

Osteonecrosis of the femoral head (ONFH) is commonly detected in young patients and most surgeons tend to delay total hip arthroplasty (THA) until the end stage of the disease. We hypothesised that post-operative range of motion (ROM) of the hip as well as baseline ROM at the time of surgery decreases with the disease progression. The purpose of this study was to determine whether patients, who were operated at an advanced stage, have pre- and post-operative hip ROM similar to ROM of patients, who were operated at earlier stages.

METHODS

Eight hundred and fifty patients (850 hips) treated with THA for ONFH were classified according to pre-operative stages of Association Research Circulation Osseous (ARCO). Fifty-six patients were operated at stage 2, 458 at stage 3, and 336 at stage 4. Pre-operative and one year post-operative ROM was compared among the stages.

RESULTS

Pre-operative sum of hip ROM decreased with the progression of ARCO stage (P < 0.001) and correlated with the post-operative sum of hip ROM (correlation coefficient 0.661). Although hip ROM improved after THA in all stages, post-operative ROM in patients with lower pre-operative ROM did not improve to the same level as in those with a higher pre-operative ROM (P < 0.001).

CONCLUSIONS

The progression of ONFH negatively affected post-operative hip ROM as well as baseline hip ROM at the time of THA. Surgeons should consider a delay of THA negatively affects the hip ROM after the arthroplasty, when they determine the treatment modality for ONFH patients.