Bisphosphonate combination therapy for non-femoral avascular necrosis

Effectiveness of various interventions for non-traumatic osteonecrosis: a pairwise and network meta-analysis

Background

Osteonecrosis of the femoral head (ONFH) is acknowledged as a prevalent, challenging orthopedic condition for patients.

Purpose

This study aimed to evaluate the efficacy of various interventions for non-traumatic ONFH and provide guidance for clinical decision-makers.

Methods

We searched PubMed, Embase, Cochrane Library, and Web of Science databases from inception to February 2023 for relevant randomized controlled trials evaluating treatments for femoral head necrosis, without language restrictions. Quality evaluation was performed using the Cochrane risk-of-bias assessment tool, and analysis was performed using Stata 15.1.

Results

Eleven randomized controlled trials were included in this study. The meta-analysis results revealed that CellTherapy [MD= -3.46, 95%CI= (-5.06, -1.85)], InjectableMed [MD= -3.68, 95%CI= (-6.11, -1.21)], ESWT [MD= -2.84, 95%CI= (-4.23, -1.45)], ESWT+InjectableMed [MD= -3.86, 95%CI= (-6.22, -1.53)] were significantly more effective in improving VAS pain score than CD+PTRI, as well as CD+BG+CellTherapy, and CD+BG. Furthermore, CD+BG+CellTherapy was better than CD+BG [MD= -0.97, 95%CI= (-1.71, -0.19)]. The SUCRA ranking for HHS score indicated that CellTherapy (77%) has the best effectiveness rate, followed by ESWT+InjectableMed (72.2%), ESWT (58.3%), InjectableMed (50%), CD+PTRI (31.4%), and CD+BG (11%). In terms of WOMAC and Lequesne scores, the meta-analysis showed no statistically significant differences between the experimental group CD+BG+CellTherapy and the control group CD+BG.

Conclusion

CellTherapy and non-surgical ESWT combined with medication or CellTherapy have the best effect on ONFH. Surgical CD+BG combined with CellTherapy is more effective than CD+BG alone. ESWT+InjectableMed is recommended for short-term or acute onset patients, while ESWT is recommended for long-term patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024540122.

Huogu injection protects against SONFH by promoting osteogenic differentiation of BMSCs and preventing osteoblast apoptosis

To investigate the effect and mechanism of Huogu injection (HG) on steroid-induced osteonecrosis of the femoral head (SONFH), we established a SONFH model in rabbits using horse serum and dexamethasone (DEX) and applied HG locally at the hip joint. We evaluated the therapeutic efficacy at 4 weeks using scanning electron microscopy (SEM), micro-CT, and qualitative histology including H&E, Masson's trichrome, ALP, and TUNEL staining. In vitro, we induced osteogenic differentiation of bone marrow stromal cells (BMSCs) and performed analysis on days 14 and 21 of cell differentiation. The findings, in vivo, including SEM, micro-CT, and H&E staining, showed that HG significantly maintained bone quality and trabecular number. ALP staining indicated that HG promoted the proliferation of bone cells. Moreover, the results of Masson's trichrome staining demonstrated the essential role of HG in collagen synthesis. Additionally, TUNEL staining revealed that HG reduced apoptosis. ALP and ARS staining in vitro confirmed that HG enhanced osteogenic differentiation and mineralization, consistent with the WB and qRT-PCR analysis. Furthermore, Annexin V-FITC/PI staining verified that HG inhibited osteoblast apoptosis, in agreement with the WB and qRT-PCR analyses. Furthermore, combined with the UPLC analysis, we found that naringin enhanced the osteogenic differentiation and accelerated the deposition of calcium phosphate. Salvianolic acid B protected osteoblasts derived from BMSCs against GCs-mediated apoptosis. Thus, this study not only reveals the mechanism of HG in promoting osteogenesis and anti-apoptosis of osteoblasts but also identifies the active-related components in HG, by which we provide the evidence for the application of HG in SONFH.

Core decompression is superior to nonoperative management for humeral head osteonecrosis: a systematic review

BACKGROUND

Much of the literature on osteonecrosis has traditionally focused on the hip, which remains the most common site for this disease. The shoulder and the knee are the second most frequently affected sites (both approximately 10% of the incidence). There are a variety of techniques for managing this disease, and it is important to optimize this for our patients. This review aimed to compare the results of core decompression (CD) vs. nonoperative modalities for the treatment of osteonecrosis of the humeral head, including (1) success rate defined as lack of progression to further procedures (shoulder arthroplasty) and no need for further intervention; (2) clinical results (patient-reported pain and functional scores); and (3) radiological outcomes.

METHODS

We queried PubMed and found 15 reports that fit the inclusion criteria for studies concerning the use of CD as well as studies discussing nonoperative treatment for stage I-III osteonecrotic lesions of the shoulder. A total of 9 studies encompassed 291 shoulders that underwent CD analyzed at a mean follow-up of 8.1 years (range, 67 months-12 years), and 6 studies examined 359 shoulders that underwent nonoperative management at a mean follow-up of 8.1 years (range, 35 months-10 years). Outcomes of CD and nonoperative management included success rate, number of shoulders requiring shoulder arthroplasty, and evaluation of several normalized patient-reported outcomes. We also assessed radiographic progression (pre- to postcollapse or further collapse progression).

RESULTS

The mean success rate of CD for avoiding further procedures was 76.6% (226 of 291 shoulders) in stage I through stage III. Stage III shoulders avoided shoulder arthroplasty in 63% (27 of 43 shoulders). Nonoperative management resulted in a success rate of 13%, P < .001. In the CD studies, 7 of 9 showed improvements in clinical outcome measurements compared with 1 of 6 of the nonoperative studies. Radiographically, there was less progression in the CD group (39 of 191 shoulders [24.2%]) vs. the nonoperative group (39 of 74 shoulders [52.3%]) (P < .001).

CONCLUSIONS

Given the high success rate and positive clinical outcomes reported, CD is an effective method for management, especially when compared with nonoperative treatment methods for stage I-III osteonecrosis of the humeral head. The authors believe that it should be used as treatment to avoid arthroplasty in patients who have osteonecrosis of the humeral head.

Astaxanthin as a Potent Antioxidant for Promoting Bone Health: An Up-to-Date Review

In recent years, bone loss and its associated diseases have become a significant public health concern due to increased disability, morbidity, and mortality. Oxidative stress and bone loss are correlated, where oxidative stress suppresses osteoblast activity, resulting in compromised homeostasis between bone formation and resorption. This event causes upregulation of bone remodeling turnover rate with an increased risk of fractures and bone loss. Therefore, supplementation of antioxidants can be proposed to reduce oxidative stress, facilitate the bone remodeling process, suppress the initiation of bone diseases, and improve bone health. Astaxanthin (3,3'-dihydroxy-4-4'-diketo-β-β carotene), a potent antioxidant belonging to the xanthophylls family, is a potential ROS scavenger and could be a promising therapeutic nutraceutical possessing various pharmacological properties. In bone, astaxanthin enhances osteoblast differentiation, osteocytes numbers, and/or differentiation, inhibits osteoclast differentiation, cartilage degradation markers, and increases bone mineral density, expression of osteogenic markers, while reducing bone loss. In this review, we presented the up-to-date findings of the potential anabolic effects of astaxanthin on bone health in vitro, animal, and human studies by providing comprehensive evidence for its future clinical application, especially in treating bone diseases.

Diagnosis and treatment of avascular necrosis of the humeral head: Current concepts

Avascular necrosis (AVN) of the humeral head is an uncommon clinical entity which can result in significant morbidity for patients. There is a paucity of literature concerning humeral head AVN, which may be due to the relatively rarity of the condition and poorly understood nature. Despite being first described decades ago, the underlying pathophysiology leading to humeral head AVN is still poorly defined. While the staging of humeral head AVN is well described, not much is known about prognosticating factors to predict the eventual course. Most of the management options are based on that of femoral head AVN, and even so, there is a paucity of good quality clinical trials in the literature. This current concepts paper describes what is known about humeral head AVN and proposes a management algorithm to guide clinicians.

[Drug treatment of osteonecrosis]

The medicinal treatment of osteonecrosis is described as part of the conservative treatment for atraumatic femoral head necrosis of the hip in adults and for Ahlbäck's disease of the knee joint. For femoral head necrosis, iloprost is used in the early stages (ARCO I and II) as a treatment attempt to eliminate pain and the accompanying bone marrow edema. This also applies to the use of bisphosphonates, whereby preferably small defects (< 30%) are suitable for treatment. Bisphosphonates are successfully used in the knee joint to treat Ahlbäck's disease, although the results are sometimes contradictory. Other locations, such as the humeral head, talus, scaphoid, lunate, proximal tibia, and metatarsal head, are sometimes successfully treated with bisphosphonates. Although the results seem promising, the groups are far too small to derive treatment recommendations in this regard.

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

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

A Paradigm Shift in Osteonecrosis Treatment with Bisphosphonates: A 20-Year Study

Bisphosphonates are proven to be effective in obviating the need for surgical intervention in osteonecrosis of the femoral head. However, the late onset of pain relief hampers compliance. We present the clinical and radiographic outcome of a combination therapy compared with alendronate-only therapy for the management of osteonecrosis of the femoral head.

Core Decompression with Local Administration of Zoledronate and Enriched Bone Marrow Mononuclear Cells for Treatment of Non-Traumatic Osteonecrosis of Femoral Head

Objective

To investigate the efficacy and safety of core decompression (CD) with local administration of zoledronate and enriched bone marrow mononuclear cells (BMMCS) for the treatment of non‐traumatic osteonecrosis of femoral head (ONFH).

Methods

A total of 17 patients (30 hips) diagnosed with stage II and III ONFH according to the 2019 revised Association for Research on Osseous Circulation (ARCO) staging criteria from 2012 to 2014 were retrospectively reviewed. The patients received the following therapy: the BMMCs and zoledronate were injected into the necrotic zone, respectively, along with CD. The mean age of the patients was 36.8 years; 14 were men and three were women. All patients included had non‐traumatic ONFH and a minimum follow‐up of 5 years, which ended when total hip arthroplasty (THA) was performed. Imaging modalities, including plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) were taken pre‐ and postoperatively. Harris hip score (HHS) was used to evaluate the functional outcomes of femoral head necrosis. Kaplan–Meier analysis was adopted to determine the probability of survivorship with THA as the end point in this series of patients. The correlation between radiological progression or THA and related risk factors were further analyzed. All complications were recorded.

Results

With THA as the follow‐up endpoint, All patients were followed up for an average of 69.1 ± 20.5 months (range, 18–95 months). Preoperative imaging found six hips (20%) at ARCO stage II, 14 hips (46.7%) at stage IIIA, 10 hips (33.3%) at stage IIIB. Fourteen hips (46.7%) shown progression radiologically, while six hips (20%) underwent TKA among these patients with hip preservation. The cumulative survival was 80% (95% CI, 0.608–905) at 5 years with THA as the end point. HHS improved from 63.3 ± 8.7 preoperatively to 74.6 ± 20.6 postoperatively (P = 0.000). Radiological progression was found to be associated with ARCO stage, Japanese Investigation Committee (JIC) type, and corticosteroid exposure (P = 0.047; P = 0.012; P = 0.031). However, no correlation was found between conversion to THA and the known risk factors. No major complication was reported, with only four patients complaining about general weakness and muscle soreness, and all disappeared within 2–3 days.

Conclusions

The novel treatment modality could relieve pain, delay the progression of collapse, which might be an effective and safe method for hip preservation of early and mid‐term ONFH. However, the effect of this method may be related to ARCO stage, JIC type, and corticosteroid exposure.

Outcome of Pantalar Fusion With Femoral Head Allograft in Avascular Necrosis of Talus

Background: Avascular necrosis (AVN) of the talus is a challenging condition that is caused primarily by trauma. The severity of the talus fracture determines the risk of AVN. Severe osteonecrosis with the loss of talar integrity can be treated with arthrodesis and structural bone graft.

Method: This study shows the experience of pantalar arthrodesis using hindfoot arthrodesis nail, screw fixation, and femoral head allograft in four patients.

Result: All patients were satisfied in terms of pain and function after an average of 4 months postsurgery. Limb length discrepancy was <1 cm and hindfoot fusion was achieved by 3 months. The mean score for SF-36 physical function and AOFAS hindfoot score at a 2-year postpantalar arthrodesis was 88 and 80.8, respectively.

Conclusion: Hindfoot ankle arthrodesis, with the usage of femoral head allograft, can be successfully used for the treatment of traumatic AVN of talus.

Antiresorptive treatment and talar collapse after displaced fractures of the talar neck: a long-term follow-up of 19 patients

Background and purpose - Displaced fractures of the talar neck are associated with a high risk of structural collapse. In this observational analysis we hypothesized that pharmacological inhibition of osteoclast function might reduce the risk of structural collapse through a reduction in bone resorption during revascularization of the injured bone.Patients and methods - Between 2002 and 2014 we treated 19 patients with displaced fractures of the talar neck with open reduction and internal fixation. Of these, 16 patients were available for final follow-up between January and November 2017 (median 12 years, IQR 7-13). Among these, 6 patients with Hawkins type 3 fractures and 2 patients with Hawkins type 2b fractures received postoperative antiresorptive treatment (7 alendronate, 1 denosumab) for 6 to 12 months. The remaining 8 patients received no antiresorptive treatment. The self-reported foot and ankle score (SEFAS) was available in all patients and 15 patients had undergone computed tomography (CT) at final follow-up, which allowed evaluation of structural collapse of the talar dome and signs of post-traumatic osteoarthritis.Results - The risk for partial collapse of the talar dome was equal in the 2 groups (3 in each group) and post-traumatic arthritis was observed in all patients. The SEFAS in patients with antiresorptive treatment was lower, at 21 points (95% CI 15-26), compared with those without treatment, 29 points (CI 22-35).Interpretation - Following a displaced fracture of the talar neck, we found no effect of antiresorptive therapy on the rate of talar collapse, post-traumatic osteoarthritis, and patient-reported outcomes.

Risk factors for symptomatic Avascular Necrosis (AVN) in a multi-ethnic Systemic Lupus Erythematosus (SLE) cohort

Avascular necrosis of bone (AVN) is increasingly being recognized as a complication of SLE and causes significant disability due to pain and mobility limitations. We studied the prevalence and factors associated with avascular necrosis (AVN) in a multiethnic SLE cohort. SLE patients who visited the outpatient clinic from October 2017 to April 2019 were considered eligible. Their medical records were reviewed to identify patients who developed symptomatic AVN, as confirmed by either magnetic resonance imaging or plain radiography. Subsequently, their SLE disease characteristics and treatment were compared with the characteristics of patients who did not have AVN. Multivariable logistic regression analyses were performed to determine the independent factors associated with AVN among the multiethnic SLE cohort. A total of 390 patients were recruited, and the majority of them were females (92.6%); the patients were predominantly of Malay ethnicity (59.5%), followed by Chinese (35.9%) and Indian (4.6%). The prevalence of symptomatic AVN was 14.1%, and the mean age of AVN diagnosis was 37.6 ± 14.4 years. Both univariate and multivariable logistic regression analyses revealed that a longer disease duration, high LDL-C (low density lipoprotein cholesterol), positive anti-cardiolipin (aCL) IgG and anti-dsDNA results, a history of an oral prednisolone dose of more than 30 mg daily for at least 4 weeks and osteoporotic fractures were significantly associated with AVN. On the other hand, hydroxychloroquin (HCQ), mycophenolate mofetil (MMF) and bisphosphonate use were associated with a lower risk of AVN. No associations with ethnicity were found. In conclusion, several modifiable risk factors were found to be associated with AVN, and these factors may be used to identify patients who are at high risk of developing such complications. The potential protective effects of HCQ, MMF and bisphosphonates warrant additional studies.

[Treatment of osteonecrosis of the femoral head with vascularized bone grafting]

OBJECTIVE

To summarize the current progress of vascularized bone grafting in the treatment of osteonecrosis of the femoral head (ONFH), and to provide reference for treatment of ONFH.

METHODS

The literature at home and abroad on the treatment of ONFH with vascularized bone grafting was reviewed, and the mechanism, operating methods and effectiveness, indications, and complications were summarized.

RESULTS

Vascularized bone grafting is a commonly used clinical hip-preserving operation. By replacing necrotic bone tissue with vascularized bone, it can rebuild the blood circulation system, promote the healing of the necrotic area, and provide biomechanical support for the necrotic area of the femoral head, prevent the joint surface collapse. The main operations include the vascularized iliac bone flap grafting, the vascularized greater trochanter bone flap grafting, and the vascularized fibular grafting. The clinical application has achieved certain effectiveness, and the different procedures are suitable for different types of patients. The procedures need to be selected based on the patient's overall condition, the cause of ONFH, the necrosis stage, and the degree of the evaluation.

CONCLUSION

Vascularized bone grafting has a definite effectiveness in the treatment of ONFH in the young and middle-aged. It can significantly improve hip joint function, control the further development of the disease to a great extent, effectively delay or even avoid hip arthroplasty. It is a reliable hip-preserving operation worthy of promotion.

Local administration of zoledronic acid prevents traumatic osteonecrosis of the femoral head in rat model

Background

Osteonecrosis of the femoral head (ONFH) is a refractory disease due to its unclear pathomechanism. Neither conservative treatment nor surgical treatment during the early stage of ONFH achieves satisfactory results. Therefore, this study aims to explore the available evidence on the effect of zoledronic acid on early-stage ONFH.

Methods

For groups were established:the Normal group, model group, Normal saline group(NS group) and zoledronic acid-treated group. The blood supply to the femoral head of animals in the model group and zoledronic acid-treated group was interrupted via a surgical procedure, and zoledronic acid was then locally administered to the femoral head. Four weeks after surgery, all the hips were harvested and evaluated by micro-CT and histopathology(H&E staining, TRAP staining, Toluidine blue staining and masson staining).

Results

The values of BMD, BS/BV and Tb.Th in the Normal group and zoledronic acid-treated group were significantly higher than those in the model group and NS group (p ​< ​0.05). The outcome of H&E staining, Toluidine blue staining and masson staining were consistent with that of micro-CT.

Conclusion

The local administration of zoledronic acid in the femoral head had positive effects on the bone structure of the femoral head in a modified rat model of traumatic ONFH and offered a promising therapeutic strategy during the early stage of ONFH.

The Translational potential of this article

This article could provide a choice for treating patients who have osteonecrosis of femora head and can be the basic research for advanced development over this disease

Do Bisphosphonates Alleviate Pain in Children? A Systematic Review

PURPOSE OF REVIEW

The goal of this systematic review is to analyze the effectiveness of bisphosphonates (BPs) to treat bone pain in children and adolescents who have diseases with skeletal involvement.

RECENT FINDINGS

We included 24 studies (2 randomized controlled trials, 3 non-randomized controlled trials, 10 non-randomized open-label uncontrolled studies, 8 retrospective studies, and 1 study with design not specified). The majority of included studies assessed pain from a unidimensional approach, with pain intensity the most frequently evaluated dimension. Only 38% of studies used validated tools; visual analogue scale was the most frequently employed. BPs were used to alleviate bone pain in a wide variety of pediatrics conditions such as osteogenesis imperfecta, secondary osteoporosis, osteonecrosis related to chemotherapy, chronic non-bacterial osteitis, idiopathic juvenile osteoporosis, unresectable benign bone tumor, and cancer-related pain. Twenty of the 24 studies reported a positive effect of BPs for alleviating pain in different pathologies, but 58% of the studies were categorized as having high risk of bias. Intravenous BPs are helpful in alleviating bone pain in children and adolescents. It is advised that our results be interpreted with caution due to the heterogeneity of the doses used, duration of treatments, and types of pathologies included. In addition, this review shows the paucity of high-quality evidence in the available literature and further research is needed.

TRIAL REGISTRATION

Before the completion of this review, the protocol was registered to PROSPERO (International prospective register of systematic reviews), PROSPERO 2020 ID # CRD42020158316. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020158316.

Management of osteonecrosis of the femoral head

Aims

Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques.

Methods

A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated.

Results

The rate of joint-preserving procedures was significantly higher in patients aged < 50 years compared with those aged > 50 years (4.93% vs 1.52%; p < 0.001). For the overall cohort, rates of arthroplasty were far greater than those for joint-preserving procedures. THA was the most commonly performed procedure (291,114; 94.03%), while osteotomy (3,598; 1.16%), partial arthroplasty (9,171; 2.96%), core decompression (1,200; 0.39%), and bone graft (3,026; 0.98%) were performed markedly less frequently. The annual percentage of patients managed using a THA (93.56% to 89.52%; p < 0.001), resurfacing (1.22% to 0.19%; p < 0.001), and osteotomy (1.31% to 1.05%; p < 0.001) also decreased during the study period.

Conclusion

We found that patients with ONFH have been most commonly managed with non-joint-preserving procedures. Our findings provide valuable insight into the current management of this condition and should increase efforts being made to save the hip joint. Cite this article: Bone Joint J 2020;102-B(7 Supple B):122–128.