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Badescu MC, Rezus E, Ciocoiu M, Badulescu OV, Butnariu LI, Popescu D, Bratoiu I, Rezus C. Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications. Int J Mol Sci 2022; 23:ijms23020640. [PMID: 35054824 PMCID: PMC8776054 DOI: 10.3390/ijms23020640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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Rezus E, Tamba BI, Badescu MC, Popescu D, Bratoiu I, Rezus C. Osteonecrosis of the Femoral Head in Patients with Hypercoagulability-From Pathophysiology to Therapeutic Implications. Int J Mol Sci 2021; 22:ijms22136801. [PMID: 34202897 PMCID: PMC8268880 DOI: 10.3390/ijms22136801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis of the femoral head (ONFH) is a debilitating disease with major social and economic impacts. It frequently affects relatively young adults and has a predilection for rapid progression to femoral head collapse and end-stage hip arthritis. If not diagnosed and treated properly in the early stages, ONFH has devastating consequences and leads to mandatory total hip arthroplasty. The pathophysiology of non-traumatic ONFH is very complex and not fully understood. While multiple risk factors have been associated with secondary ONFH, there are still many cases in which a clear etiology cannot be established. Recognition of the prothrombotic state as part of the etiopathogeny of primary ONFH provides an opportunity for early medical intervention, with implications for both prophylaxis and therapy aimed at slowing or stopping the progression of the disease. Hereditary thrombophilia and hypofibrinolysis are associated with thrombotic occlusion of bone vessels. Anticoagulant treatment can change the natural course of the disease and improve patients' quality of life. The present work focused on highlighting the association between hereditary thrombophilia/hypofibrinolysis states and ONFH, emphasizing the importance of identifying this condition. We have also provided strong arguments to support the efficiency and safety of anticoagulant treatment in the early stages of the disease, encouraging etiological diagnosis and prompt therapeutic intervention. In the era of direct oral anticoagulants, new therapeutic options have become available, enabling better long-term compliance.
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Affiliation(s)
- Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy Iași, 16 University Street, 700115 Iasi, Romania; (E.R.); (I.B.)
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Bogdan Ionel Tamba
- Advanced Center for Research and Development in Experimental Medicine (CEMEX), “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 9-13 Mihail Kogălniceanu Street, 700454 Iasi, Romania;
| | - Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence:
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy Iași, 16 University Street, 700115 Iasi, Romania; (E.R.); (I.B.)
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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Xu Q, Chen H, Chen S, Shan J, Xia G, Cao Z, Liu X, Dai M. Development and validation of a nomogram for predicting the probability of nontraumatic osteonecrosis of the femoral head in Chinese population. Sci Rep 2020; 10:20660. [PMID: 33244062 PMCID: PMC7691506 DOI: 10.1038/s41598-020-77693-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 11/12/2020] [Indexed: 11/18/2022] Open
Abstract
Although corticosteroids and alcohol are two major risk factors for nontraumatic osteonecrosis of the femoral head (NONFH), the effects of other factors have rarely been studied, thereby making early diagnosis and treatment of NONFH difficult. This study aimed to develop and validate a nomogram to NONFH, but patients with alcohol- and steroid-related NONFH are not at all taken into account in this study. A training cohort of 790 patients (n = 434, NONFH; n = 356, femoral neck fractures [non-NONFH]) diagnosed in our hospital from January 2011 to December 2016 was used for model development. A least absolute shrinkage and selection operator (lasso) regression model was used for date dimension reduction and optimal predictor selection. A predictive model was developed from univariate and multivariate logistic regression analyses. Performance characterisation of the resulting nomogram included calibration, discriminatory ability, and clinical usefulness. After internal validation, the nomogram was further evaluated in a separate cohort of 300 consecutive patients included between January 2017 and December 2018. The simple prediction nomogram included five predictors from univariate and multivariate analyses, including gender, total cholesterol levels, triglyceride levels, white blood cell count, and platelet count. Internal validation showed that the model had good discrimination [area under the receiver operating characteristic curve (AUC) = 0.80] and calibration. Good discrimination (AUC = 0.81) and calibration were preserved in the validation cohort. Decision curve analysis showed that the predictive nomogram was clinically useful. The simple diagnostic nomogram, which combines demographic data and laboratory blood test results, was able to quantify the probability of NONFH in cases of early screening and diagnosis.
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Affiliation(s)
- Qiang Xu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China
| | - Hangjun Chen
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China
| | - Sihai Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Jiangxi Institute of Gastroenterology and Hepatology, Nanchang, 330006, Jiangxi province, China
| | - Jing Shan
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China
| | - Guoming Xia
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China
| | - Zhiyou Cao
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China
| | - Xuqiang Liu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China.
| | - Min Dai
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, 330006, Jiangxi province, China.
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Serrano-Toledano D, del Río-Arteaga M, Ribera-Zabalbeascoa J. Transient familial factor V Leiden-linked hip osteoporosis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020. [DOI: 10.1016/j.recote.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Serrano-Toledano D, Del Río-Arteaga M, Ribera-Zabalbeascoa J. Transient Familial Factor V Leiden-Linked Hip Osteoporosis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 64:286-289. [PMID: 32229104 DOI: 10.1016/j.recot.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/29/2019] [Accepted: 12/21/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Transient osteoporosis of the hip (THO) is a rare disease of unknown pathogenesis that has traditionally been considered an early and reversible stage of avascular necrosis (AN). Thrombophilia or familial hypofibrinolysis is considered a risk factor for the development of AN and THO. Factor V Leiden is one of the most common hereditary hypercoagulability disorders. CLINICAL CASES Case series study. The development and course of 3THO cases in 3siblings (two males and one female) aged between 40 and 43 years are described consecutively. Clinical and nuclear magnetic resonance imaging (MRI) studies confirmed the diagnosis of THO and ruled out the presence of AN. The G1691A mutation of factor v Leiden was positive in all cases. The clinical and radiological outcome was favourable, with healing without sequelae and disappearance of bone oedema on control MRI at 6 months in all cases. DISCUSSION The results of this study support the ischaemic aetiology and establish HTO as an early and reversable stage of hip AN. Factor V Leiden causes a state of hypercoagulability and hypofibrinolysis that encourages the development of THO due to ischaemic causes. CONCLUSIONS This study outlines the first familiar description of factor v Leiden-linked THO.
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Affiliation(s)
- D Serrano-Toledano
- Unidad de Cadera y Rodilla, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España; Hospital Comarcal Básico de Riotinto, Huelva, España.
| | - M Del Río-Arteaga
- Unidad de Cadera y Rodilla, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España; Unidad de Cadera y Rodilla, Hospital San Juan de Dios Aljarafe, Sevilla, España
| | - J Ribera-Zabalbeascoa
- Unidad de Cadera y Rodilla, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España
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Serong S, Haversath M, Jäger M, Landgraeber S. Prevalence of CAM deformity and its influence on therapy success in patients with osteonecrosis of the femoral head. J Tissue Eng Regen Med 2019; 13:546-554. [PMID: 30636359 DOI: 10.1002/term.2794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/17/2018] [Indexed: 12/19/2022]
Abstract
Osteonecrosis of the femoral head (ONFH) and CAM-type femoroacetabular impingement (FAI) present two different pathologies of the hip joint. The aim of this study is to describe the prevalence of CAM-FAI in a collective of ONFH hips and to evaluate its influence on ONFH therapy outcome. A cohort of 86 ONFH hips with a mean follow-up of 46.7 months (±20.5) after advanced core decompression (ACD) was evaluated regarding CAM deformity by measuring the alpha angle (α) and head-neck offset. The influence of CAM-type FAI was investigated using the Kaplan-Meier estimator and the Cox regression model. The mean α was 60.4° (±13.8) with 41 hips (47.7%) being ≥60°. The mean head-neck offset was 4.5 mm (±3.2), with 78 hips (90.7%) being ≤9 mm. Survival analysis indicated noticeably better ACD results for α < 60° versus α ≥ 60° (p = 0.07). Treatment failure within the first 2 years was statistically estimated as 27.7% for α < 60° versus 40.7% for α ≥ 60°: The hazard ratio for α ≥ 60° was 1.94. Head-neck offset-dependent survival showed better, though not significant, results for offset >9 mm (p = 0.38, hazard ratio 1.89 for offsets ≤9 mm). The prevalence of CAM-type deformity is greatly increased in patients with concomitant ONFH. There is a strong indication that CAM-type FAI has a negative influence on ONFH therapy outcome. The risk that ONFH treatment will fail seems to be twice as high for α ≥ 60° as for α < 60°. We recommend cotreatment of pathological head-neck offset in patients with ONFH.
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Affiliation(s)
- Sebastian Serong
- Department of Orthopaedics and Traumatology, University of Duisburg-Essen, Essen, Germany.,Department of Orthopaedics and Orthopaedic Surgery, Saarland University, Homburg, Germany
| | - Marcel Haversath
- Department of Orthopaedics and Traumatology, University of Duisburg-Essen, Essen, Germany
| | - Marcus Jäger
- Department of Orthopaedics and Traumatology, University of Duisburg-Essen, Essen, Germany
| | - Stefan Landgraeber
- Department of Orthopaedics and Traumatology, University of Duisburg-Essen, Essen, Germany.,Department of Orthopaedics and Orthopaedic Surgery, Saarland University, Homburg, Germany
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Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 1: Glucocorticoid-Associated Osteonecrosis. J Arthroplasty 2019; 34:163-168.e1. [PMID: 30348552 DOI: 10.1016/j.arth.2018.09.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/28/2018] [Accepted: 09/10/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Glucocorticoid usage, a leading cause of osteonecrosis of the femoral head (ONFH), and its prevalence was reported in 25%-50% of non-traumatic ONFH patients. Nevertheless, there have been no unified criteria to classify glucocorticoid-associated ONFH (GA-ONFH). In 2015, the Association Research Circulation Osseous addressed the issue of developing a classification scheme. METHODS In June 2017, a task force was set up to conduct a Delphi survey concerning ONFH. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey consists of questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, the panel reached a consensus on the classification criteria. The response rates were 100% (Round 1), 96% (Round 2), and 100% (Round 3), respectively. RESULTS The consensus on the classification criteria of GA-ONFH included the following: (1) patients should have a history of glucocorticoid use >2 g of prednisolone or its equivalent within a 3-month period; (2) osteonecrosis should be diagnosed within 2 years after glucocorticoid usage, and (3) patients should not have other risk factor(s) besides glucocorticoids. CONCLUSION Association Research Circulation Osseous established classification criteria to standardize clinical studies concerning GA-ONFH.
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Yoon BH, Jones LC, Chen CH, Cheng EY, Cui Q, Drescher W, Fukushima W, Gangji V, Goodman SB, Ha YC, Hernigou P, Hungerford M, Iorio R, Jo WL, Khanduja V, Kim H, Kim SY, Kim TY, Lee HY, Lee MS, Lee YK, Lee YJ, Mont MA, Sakai T, Sugano N, Takao M, Yamamoto T, Koo KH. Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 2: Alcohol-Associated Osteonecrosis. J Arthroplasty 2019; 34:169-174.e1. [PMID: 30348559 DOI: 10.1016/j.arth.2018.09.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/28/2018] [Accepted: 09/10/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although alcohol is a leading risk factor for osteonecrosis of the femoral head (ONFH) and its prevalence reportedly ranges from 20% to 45%, there are no unified classification criteria for this subpopulation. In 2015, Association Research Circulation Osseous decided to develop classification criteria for alcohol-associated ONFH. METHODS In June of 2017, Association Research Circulation Osseous formed a task force to conduct a Delphi survey. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey included questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, consensus was reached on the classification criteria. The response rates for the 3 Delphi rounds were 100% (round 1), 96% (round 2), and 100% (round 3). RESULTS The consensus on the classification criteria of alcohol-associated ONFH included the following: (1) patients should have a history of alcohol intake >400 mL/wk (320 g/wk, any type of alcoholic beverage) of pure ethanol for more than 6 months; (2) ONFH should be diagnosed within 1 year after alcohol intake of this dose; and (3) patients should not have other risk factor(s). CONCLUSION ARCO-established classification criteria to standardize clinical studies concerning AA-ONFH.
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Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, South Korea
| | - Lynne C Jones
- Department of Orthopaedic Surgery, Center for Metabolism and Obesity Research Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chung-Hwan Chen
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Edward Y Cheng
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Wolf Drescher
- Department of Orthopedic and Trauma Surgery, RWTH Aachen University, Aachen, Germany
| | - Wakaba Fukushima
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Valerie Gangji
- Department of Rheumatology and Physical Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Philippe Hernigou
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, Creteil, France
| | - Marc Hungerford
- Department of Orthopedic Surgery, Mercy Medical Center, Baltimore, MD
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Woo-Lam Jo
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Vikas Khanduja
- Department of Trauma & Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Harry Kim
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Shin-Yoon Kim
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Tae-Young Kim
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, South Korea
| | - Hee Young Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Mel S Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yun Jong Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital and Medical College of Seoul National University, Seongnam, South Korea
| | - Michael A Mont
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, MD
| | - Takashi Sakai
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaki Takao
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
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Testosterone Therapy, Thrombophilia, Venous Thromboembolism, and Thrombotic Events. J Clin Med 2018; 8:jcm8010011. [PMID: 30577621 PMCID: PMC6352146 DOI: 10.3390/jcm8010011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 01/24/2023] Open
Abstract
In our sequential studies of 67 and 21 patients, testosterone therapy (TT) interacted with thrombophilia⁻hypofibrinolysis, leading to venous thromboembolism (VTE). Compared to 111 VTE controls not taking TT (VTE-no TT), the 67 and 21 cases were more likely (p < 0.05 for all) to have Factor V Leiden (FVL) heterogeneity (24% and 33% vs. 12%), the lupus anticoagulant (14% and 33% vs. 4%), and high lipoprotein(a) (33% vs. 13%, n = 21). After a first VTE and continuing TT, 11 thrombophilic cases had a second VTE despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third VTE. The greatest density of thrombotic events was at three months after starting TT, with a rapid decline by 10 months. From <1 to 8 months after starting TT, 65% of VTE occurred, which may reflect TT-induced depletion of susceptible thrombophilic patients, leaving a winnowed residual group with fewer VTE events despite the continuation of TT. Before starting TT, we suggest screening for FVL, lipoprotein(a), and the lupus anticoagulant to identify patients at increased VTE risk, with an adverse risk-to-benefit ratio for TT. We suggest that TT should not be started in patients with known thrombophilia⁻hypofibrinolysis, and should not be continued after a first VTE. When TT is given to patients with thrombophilia⁻hypofibrinolysis, VTE may occur and then recur despite adequate anticoagulation.
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Glueck CJ, Goldenberg N, Wang P. Thromboembolism peaking 3 months after starting testosterone therapy: testosterone–thrombophilia interactions. J Investig Med 2017; 66:733-738. [DOI: 10.1136/jim-2017-000637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
We assessed time of thrombotic events (venous thromboembolism (VTE)) after starting testosterone therapy (TT) in 21 men who sustained 23 VTE. The density of thrombotic events was greatest at 3 months after starting TT, with a rapid decline in events by 10 months. The 21 cases with VTE on TT differed from 110 patient controls with unprovoked VTE, not taking TT (VTE-no TT) for Factor V Leiden heterozygosity (FVL) (33 per cent vs 13 per cent, P=0.037), for high lipoprotein (a) (Lp(a)) (55 per cent vs 17 per cent, P=0.012), and for the lupus anticoagulant (33 per cent vs 4 per cent, P=0.003). These differences between cases and VTE-no TT controls were independent of age and gender. TT can interact with underlying thrombophilia–hypofibrinolysis promoting VTE. We suggest that TT should not be started in subjects with known thrombophilia. Coagulation screening, particularly for the FVL , Lp(a), and the lupus anticoagulant should be considered before starting TT, to identify men at high VTE risk who have an adverse risk/benefit ratio for TT.
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Jarman MI, Lee K, Kanevsky A, Min S, Schlam I, Mahida C, Huda A, Milgrom A, Goldenberg N, Glueck CJ, Wang P. Case report: primary osteonecrosis associated with thrombophilia-hypofibrinolysis and worsened by testosterone therapy. BMC HEMATOLOGY 2017; 17:5. [PMID: 28361003 PMCID: PMC5368894 DOI: 10.1186/s12878-017-0076-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/17/2017] [Indexed: 11/29/2022]
Abstract
Background Familial and acquired thrombophilia are often etiologic for idiopathic hip and jaw osteonecrosis (ON), and testosterone therapy (TT) can interact with thrombophilia, worsening ON. Case presentation Case 1: A 62-year-old Caucasian male (previous deep venous thrombosis), on warfarin 1 year for atrial fibrillation (AF), had non-specific right hip-abdominal pain for 2 years. CT scan revealed bilateral femoral head ON without collapse. Coagulation studies revealed Factor V Leiden (FVL) heterozygosity, 4G/4G plasminogen activator inhibitor (PAI) homozygosity, high anti-cardiolipin (ACLA) IgM antibodies, and endothelial nitric oxide (NO) synthase (eNOS) T786C homozygosity (reduced conversion of L-arginine to NO, required for bone health). Apixaban 5 mg twice daily was substituted for warfarin; and L-arginine 9 g/day was started to increase NO. On Apixaban for 8 months, he became asymptomatic. Case 2: A 32-year-old hypogonadal Caucasian male had 10 years of unexplained tooth loss, progressing to primary jaw ON with cavitation 8 months after starting TT gel 50 mg/day. Coagulation studies revealed FVL heterozygosity, PAI 4G/4G homozygosity, and the lupus anticoagulant. TT was discontinued. Jaw pain was sharply reduced within 2 months. Conclusions Idiopathic ON, often caused by thrombophilia-hypofibrinolysis, is worsened by TT, and its progression may be slowed or stopped by discontinuation of TT and, thereafter, anticoagulation. Recognition of thrombophilia-hypofibrinolysis before joint collapse facilitates anticoagulation which may stop ON, preserving joints.
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Affiliation(s)
- Michael Ian Jarman
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Kevin Lee
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ariel Kanevsky
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Sarah Min
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ilana Schlam
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Chris Mahida
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ali Huda
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Alexander Milgrom
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Naila Goldenberg
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Charles J Glueck
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ping Wang
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
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Elmallah RK, Mont MA. Is There an Anatomic Basis for Hip Osteonecrosis? Commentary on an article by Matthieu Ollivier, MD, et al.: "Anatomical Findings in Patients Undergoing Total Hip Arthroplasty for Idiopathic Femoral Head Osteonecrosis". J Bone Joint Surg Am 2016; 98:e35. [PMID: 27098335 DOI: 10.2106/jbjs.15.01456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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13
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Glueck CJ, Riaz R, Prince M, Freiberg RA, Wang P. Testosterone Therapy Can Interact With Thrombophilia, Leading to Osteonecrosis. Orthopedics 2015; 38:e1073-8. [PMID: 26652327 DOI: 10.3928/01477447-20151120-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/08/2015] [Indexed: 02/03/2023]
Abstract
Although this effect is not widely recognized, testosterone therapy can interact with thrombophilia, causing osteonecrosis. In 12 men and 4 women who had idiopathic osteonecrosis a median of 6 months after the onset of testosterone therapy, the authors examined the interaction between testosterone therapy and previously undiagnosed thrombophilia. The authors hypothesized that patients who had osteonecrosis after starting testosterone therapy were more likely than 110 normal control subjects or 48 patients who had osteonecrosis and were not receiving testosterone therapy to have thrombophilia. Measures of thrombophilia included Factor V Leiden, prothrombin, PAI-1 gene mutations, Factor VIII, Factor XI, anticardiolipin antibody immunoglobulin G or immunoglobulin M, and homocysteine values. In 10 cases, osteonecrosis occurred 6 months or less after the onset of testosterone therapy, and in all 16 cases, it occurred after a median of 6 months of testosterone therapy. Of the 16 cases, 5 (31%) were Factor V Leiden heterozygotes vs 2 of 109 (2%) healthy control subjects (P=.0003) and 4 of 48 patients who had osteonecrosis and were not receiving testosterone therapy (P=.04). Of the 16 cases, 4 (25%) had high (>150%) Factor VIII levels vs 7 of 103 (7%) healthy control subjects (P=.04), and 3 (19%) had high (>150%) Factor XI levels vs 3 of 101 (3%) healthy control subjects (P=.03). Of the 16 patients with osteonecrosis, 14 (88%) had at least 1 abnormal procoagulant value (of the 8 measured) vs 47 of 110 (43%) healthy control subjects (P=.0009). Of the 5 men whose serum estradiol level was measured while they were receiving testosterone therapy, this level was high (≥42.6 pg/mL) in 4. When testosterone therapy is given to patients with thrombophilia, they are at increased risk for osteonecrosis.
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14
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Glueck CJ, Prince M, Patel N, Patel J, Shah P, Mehta N, Wang P. Thrombophilia in 67 Patients With Thrombotic Events After Starting Testosterone Therapy. Clin Appl Thromb Hemost 2015; 22:548-53. [PMID: 26620418 DOI: 10.1177/1076029615619486] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We compared thrombophilia in 67 cases (59 men and 8 women) with thrombotic events after starting testosterone therapy (TT) versus 111 patient controls having unprovoked venous thrombotic events without TT. In the 67 patients, thrombosis (47 deep venous thrombosis-pulmonary embolism, 16 osteonecrosis, and 4 ocular thrombosis) occurred 6 months (median) after starting TT. Cases differed from controls for factor V Leiden heterozygosity (16 of the 67 [24%] vs 13 [12%] of the 111, P = .038) and for lupus anticoagulant (9 [14%] of the 64 vs 4 [4%] of the 106, P = .019). After a first thrombotic event and continuing TT, 11 cases had a second thrombotic event, despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third thrombosis. Screening for thrombophilia before starting TT should identify men and women at high risk for thrombotic events with an adverse risk-benefit ratio for TT. When TT is given to patients with familial and acquired thrombophilia, thrombosis may occur and recur in thrombophilic men despite anticoagulation.
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Affiliation(s)
- Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Marloe Prince
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Niravkumar Patel
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Jaykumar Patel
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Parth Shah
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Nishi Mehta
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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15
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Badhiwala JH, Nayiager T, Athale UH. The development of thromboembolism may increase the risk of osteonecrosis in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2015; 62:1851-4. [PMID: 25931304 DOI: 10.1002/pbc.25553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 03/23/2015] [Indexed: 11/11/2022]
Abstract
Previous studies indicate pathophysiological and epidemiological parallels between osteonecrosis (ON) and thromboembolism (TE), two common treatment-related morbidities in acute lymphoblastic leukemia (ALL). To elucidate risk factors for ON and explore the relationship between ON and TE, we undertook a retrospective study of children (n = 208) with ALL. Twenty-one (10.1%) children developed ON and 42 (20.2%) TE on therapy. Thromboembolism was a significant predictor of ON on univariate (OR 8.85) and multivariate analysis, along with older age and PEGylated asparaginase. This observation supports a role for hypercoagulability in the pathogenesis of ON. Larger prospective studies are needed to further test these findings.
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Affiliation(s)
- Jetan H Badhiwala
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Trishana Nayiager
- Division of Hematology-Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Uma H Athale
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology-Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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16
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Freedman J, Glueck CJ, Prince M, Riaz R, Wang P. Testosterone, thrombophilia, thrombosis. Transl Res 2015; 165:537-48. [PMID: 25639953 DOI: 10.1016/j.trsl.2014.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
We screened previously undiagnosed thrombophilia (V Leiden-prothrombin mutations, Factors VIII and XI, homocysteine, and antiphospholipid antibody [APL] syndrome) in 15 men and 2 women with venous thromboembolism (VTE) or osteonecrosis 7 months (median) after starting testosterone therapy (TT), gel (30-50 mg/d), intramuscular (100-400 mg/wk), or human chorionic gonadotropin (HCG) (6000 IU/wk). Thrombophilia was studied in 2 healthy control groups without thrombosis (97 normal controls, 31 subjects on TT) and in a third control group (n = 22) with VTE, not on TT. Of the 17 cases, 76% had ≥1 thrombophilia vs 19% of 97 normal controls (P < 0.0001), vs 29% of 31 TT controls (P = 0.002). Cases differed from normal controls by Factor V Leiden (12% vs 0%, P = 0.021), by high Factor VIII (>150%) (24% vs 7%, P = 0.058), by high homocysteine (29% vs 5%, P = 0.007), and from both normal and TT controls for APL syndrome (18% vs 2%, P = 0.023, vs 0%, P = 0.04). Despite adequate anticoagulation with TT continued after the first deep venous thrombosis-pulmonary embolus (DVT-PE), 1 man sustained 3 DVT-PEs 5, 8, and 11 months later and a second man had 2 DVT-PEs 1 and 2 months later. Of the 10 cases with serum T measured on TT, 6 (60%) had supranormal T (>800 ng/dL) and of 9 with estradiol measured on TT, 7 (78%) had supranormal levels (>42.6 pg/mL). TT interacts with thrombophilia leading to thrombosis. TT continuation in thrombophilic men is contraindicated because of recurrent thrombi despite anticoagulation. Screening for thrombophilia before starting TT should identify subjects at high risk for VTE with an adverse the risk to benefit ratio for TT.
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Affiliation(s)
- Joel Freedman
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio.
| | - Marloe Prince
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Rashid Riaz
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio
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17
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Glueck CJ, Friedman J, Hafeez A, Hassan A, Wang P. Testosterone therapy, thrombophilia, and hospitalization for deep venous thrombosis–pulmonary embolus, an exploratory, hypothesis-generating study. Med Hypotheses 2015; 84:341-3. [DOI: 10.1016/j.mehy.2015.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 01/15/2015] [Indexed: 11/26/2022]
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18
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Long term anticoagulation (4-16 years) stops progression of idiopathic hip osteonecrosis associated with familial thrombophilia. Adv Orthop 2015; 2015:138382. [PMID: 25709842 PMCID: PMC4325553 DOI: 10.1155/2015/138382] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/23/2014] [Indexed: 11/17/2022] Open
Abstract
In 6 patients with familial thrombophilia (5 Factor V (FV) Leiden heterozygotes, 1 with resistance to activated protein C (RAPC)), we prospectively assessed whether continuous longterm (4–16 years) anticoagulation would prevent progression of idiopathic osteonecrosis (ON), ameliorate pain, and facilitate functional recovery. Four men and 2 women (9 hips, 8 Ficat stage II, 1 stage I) were anticoagulated with enoxaparin (60 mg/day) for 3 months and subsequently with Coumadin, Xarelto, or Pradaxa, warranted by ≥2 prior thrombotic events. Anticoagulation was continued for 4, 4, 9, 13, 13, and 16 years, with serial clinical and X-ray follow-up. On 4–16-years anticoagulation, 9 hips in the 6 patients (8 originally Ficat II, 1 Ficat I) remained unchanged, contrasted to untreated ON Ficat stage II, where 50%–80% of hips progress to collapse (Ficat stages III-IV) within 2 years after diagnosis. Within 3, 3, 3, 9, and 16 months after starting anticoagulation, 5 patients became pain-free and remained asymptomatic throughout follow-up; the 6th patient required Percocet for pain. There were no significant bleeding episodes. Long term (4–16 years) anticoagulation initiated in Ficat stages I-II of idiopathic hip ON in patients with FV-RAPC changes the natural history of ON, stopping progression, resolving pain, and restoring function.
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19
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Glueck CJ, Freiberg RA, Wang P. Medical treatment of osteonecrosis of the knee associated with thrombophilia-hypofibrinolysis. Orthopedics 2014; 37:e911-6. [PMID: 25275980 DOI: 10.3928/01477447-20140924-59] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/20/2014] [Indexed: 02/03/2023]
Abstract
In 6 patients with stage II knee osteonecrosis, all 6 with thrombophilia and 4 with concurrent hypofibrinolysis, the authors prospectively determined whether anticoagulation with enoxaparin could prevent collapse and progression to osteoarthritis, ameliorate pain, and restore function. The 6 patients were treated with enoxaparin (40 to 60 mg/d for 3 or more months) as mandated by a US Food and Drug Administration-approved protocol. In post-enoxaparin prospective follow-up, patients were reassessed clinically every 4 to 6 months, and radiographs were obtained every year. The 6 patients followed up at 15.1, 7.5, 3.9, 2.25, 2, and 1 year, respectively. None progressed to joint collapse or severe osteoarthritis. Four became and remained asymptomatic at 2-, 3.9-, 7.5-, and 15.1-year follow-up, respectively. A fifth patient did not progress to collapse or severe osteoarthritis but had residual pain at 2.25-year follow-up. The sixth patient had no symptomatic benefit on enoxaparin but improved on rivaroxaban at 1-year follow-up. Two patients had recurrences of knee pain 1 and 4 years after their initial treatment with enoxaparin. One resolved after a second course of enoxaparin, and the other, with a second recurrence 1 year after the second course, resolved after a third course. Pretreatment, all 6 patients required canes, crutches, or wheelchairs, but after enoxaparin, no patient required them, and walking was unrestricted. Thrombophilia-hypofibrinolysis contributes to the pathogenesis of knee osteonecrosis. Thrombophilic-hypofibrinolytic patients with stage II knee osteonecrosis treated with enoxaparin have had no collapse or progression to severe osteoarthritis, and most have had resolution of pain and restoration of full function. This represents a major improvement compared with the natural history of untreated spontaneous knee osteonecrosis.
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20
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Glueck CJ, Wang P. Testosterone therapy, thrombosis, thrombophilia, cardiovascular events. Metabolism 2014; 63:989-94. [PMID: 24930993 DOI: 10.1016/j.metabol.2014.05.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/06/2014] [Accepted: 05/11/2014] [Indexed: 12/13/2022]
Abstract
There are similar time intervals between starting testosterone therapy (TT) and development of thrombotic (~4.5 months) or cardiovascular (CVD) events (~3 months) which may, speculatively, reflect a shared pathophysiology. We have described thrombotic events 5 months (median) after starting TT in 38 men and 4 women, including 27 with deep venous thrombosis-pulmonary embolism, 12 with osteonecrosis, 1 with central retinal vein thrombosis, 1 with amaurosis fugax, and 1 with spinal cord infarction. In 8 men whose TT was continued, second thrombotic events occurred despite adequate anticoagulation with Coumadin in 8 men, 3 of whom had a third thrombotic event. Of these 42 cases, 40 had measures of thrombophilia-hypofibrinolysis, and 39 were found to have previously undiagnosed thrombophilia-hypofibrinolysis. Before beginning TT, especially in men with previous history of thrombotic events, we suggest that, at a minimum, measurements be made for the Factor V Leiden and Prothrombin mutations, Factors VIII and XI, and homocysteine, to identify men who should not receive TT. We need prospective data focused on whether there should be pre-TT screening based on history of previous venous thromboembolism or for all subjects for major gene thrombophilias. To better resolve questions about TT and all cause and cardiovascular morbidity and mortality and thrombosis, a long term, prospective, randomized, blinded study following the example of the Women's Health Initiative is needed. While we wait for prospective placebo-controlled TT outcome data, TT should be restricted to men with well-defined androgen deficiency syndromes.
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Affiliation(s)
- Charles J Glueck
- Jewish Hospital Cholesterol, Metabolism, Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
| | - Ping Wang
- Jewish Hospital Cholesterol, Metabolism, Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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21
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Enoxaparin prevents steroid-related avascular necrosis of the femoral head. ScientificWorldJournal 2014; 2014:347813. [PMID: 25110730 PMCID: PMC4106066 DOI: 10.1155/2014/347813] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/06/2014] [Accepted: 06/11/2014] [Indexed: 01/21/2023] Open
Abstract
Nontraumatic osteonecrosis of the femoral head is still a challenging problem in orthopedic surgery. It is responsible for 10% of the 500,000 hip replacement surgeries in the USA and affects relatively young, active patients in particular. Main reasons for nontraumatic osteonecrosis are glucocorticoid use, alcoholism, thrombophilia, and hypofibrinolysis (Glueck et al., 1997; Orth and Anagnostakos, 2013). One pathomechanism of steroid-induced osteonecrosis is thought to be impaired blood flow to the femoral head caused by increased thrombus formation and vasoconstriction. To investigate the preventive effect of enoxaparin on steroid-related osteonecrosis, we used male New Zealand white rabbits. Osteonecrosis was induced by methylprednisolone-injection (1 × 20 mg/kg body weight). Control animals were treated with phosphate-buffered saline. Treatment consisted of an injection of 11.7 mg/kg body weight of enoxaparin per day (Clexane) in addition to methylprednisolone. Four weeks after methylprednisolone-injection the animals were sacrificed. Histology (hematoxylin-eosin and Ladewig staining) was performed, and empty lacunae and histological signs of osteonecrosis were quantified. Histomorphometry revealed a significant increase in empty lacunae and necrotic changed osteocytes in glucocorticoid-treated animals as compared with the glucocorticoid- and Clexane-treated animals and with the control group. No significant difference was detected between the glucocorticoid and Clexane group and the control group. This finding suggests that cotreatment with enoxaparin has the potential to prevent steroid-associated osteonecrosis.
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Testosterone, anastrozole, factor V Leiden heterozygosity and osteonecrosis of the jaws. Blood Coagul Fibrinolysis 2014; 25:286-8. [DOI: 10.1097/mbc.0000000000000047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gómez-Puerta JA, Peris P, Reverter JC, Espinosa G, Martinez-Ferrer A, Monegal A, Monteagudo J, Tàssies D, Guañabens N. High prevalence of prothrombotic abnormalities in multifocal osteonecrosis: description of a series and review of the literature. Medicine (Baltimore) 2013; 92:295-304. [PMID: 24145698 PMCID: PMC4553995 DOI: 10.1097/md.0000000000000007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Jose A Gómez-Puerta
- From the Department of Rheumatology (JAG-P, PP, AM-F, AM, NG), CIBERehd; and Hemotherapy and Haemostasis Service (JCR, JM, DT), Hospital Clínic, Barcelona; Department of Autoimmune Diseases (GE), Hospital Clínic, University of Barcelona, Barcelona, Spain; and Division of Rheumatology, Immunology and Allergy (JAG-P), Brigham and Women's Hospital, Boston, Massachusetts, United States
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24
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Shang X, Luo Z, Li X, Hu F, Zhao Q, Zhang W. Meta-analysis of Factor V Leiden G1691A polymorphism and osteonecrosis of femoral head susceptibility. Biomed Rep 2013; 1:594-598. [PMID: 24648992 DOI: 10.3892/br.2013.93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 03/25/2013] [Indexed: 11/06/2022] Open
Abstract
Testing for genetic risk associations between Factor V Leiden (FVL) and the osteonecrosis of femoral head (ONFH) is common, however, inconsistent results have been previously obtained. To summarize results on the association of FVL mutation polymorphism with ONFH in various populations and to calculate the overall genetic risk factors, we performed a search of electronic databases including PubMed, Elsevier Science Direct, Chinese National Knowledge Infrastructure and the Chinese Biomedical Database to identify published studies correlating the FVL mutation with ONFH. Statistical analysis was performed using Review Manager (RevMan) version 5.0 and Stata statistical software (version 10). We identified 57 titles and included 7 studies comprising 481 cases and 867 controls in this meta-analysis. The groups were pooled, and a significant association between FVL mutation and increased ONFH was found (OR=4.55, 95% CI, 2.75-7.52, P<0.00001). This meta-analysis demonstrated that FVL plays an important role in non-Asian populations. Large sample studies including different ethnic groups and age- and gender-matched groups, as well as multiple gene polymorphism detection should be considered to clarify the association of FVL mutation polymorphism and ONFH susceptibility in the future.
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Affiliation(s)
- Xifu Shang
- Department of Orthopedic Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - Zhengliang Luo
- Department of Orthopedic Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - Xu Li
- Department of Orthopedic Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - Fei Hu
- Department of Orthopedic Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - Qichun Zhao
- Department of Orthopedic Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - Wenzhi Zhang
- Department of Orthopedic Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
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Carulli C, Innocenti M, Brandi ML. Bone vascularization in normal and disease conditions. Front Endocrinol (Lausanne) 2013; 4:106. [PMID: 23986744 PMCID: PMC3752619 DOI: 10.3389/fendo.2013.00106] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 08/06/2013] [Indexed: 01/14/2023] Open
Abstract
Bone vasculature is essential for many processes, such as skeletal development and growth, bone modeling and remodeling, and healing processes. Endothelium is an integral part of bone tissue, expressing a physiological paracrine function via growth factors and chemokines release, and interacting with several cellular lines. Alterations of the complex biochemical interactions between vasculature and bone cells may lead to various clinical manifestations. Two different types of pathologies result: a defect or an excess of bone vasculature or endothelium metabolism. Starting from the molecular basis of the interactions between endothelial and bone cells, the Authors present an overview of the recent acquisitions in the physiopathology of the most important clinical patterns, and the modern therapeutic strategies for their treatments.
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Affiliation(s)
- Christian Carulli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Massimo Innocenti
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
- *Correspondence: Maria Luisa Brandi, Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini, 650139 Florence, Italy e-mail:
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