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

Osteonecrosis as a manifestation of Long-COVID Syndrome: a systematic review

Purpose SARS-CoV-2 is an RNA virus responsible for COVID-19 pandemic. Some authors described the set of persistent symptoms COVID-related as "Long-COVID Syndrome." Several cases of post-COVID-19 osteonecrosis (ON) are described. Our primary aim was to study the hypothetical correlation between SARS-CoV-2 infection and ON; our secondary aim was to understand if ON can be considered part of Long-COVID. Materials and methods We performed a systematic review following the Preferred Reporting Items for Systematic Reviewers and Meta-analysis (PRISMA) guidelines. Because COVID-19 is a recently described disease, we included all levels of evidence studies. We excluded studies lacking specification regarding the use of corticosteroids (CCS) and studies not related to COVID-19. The variables extracted were age, sex, risk factors, affected joints, signs and symptoms, magnetic resonance imaging (MRI) and X-ray features, histology, treatment of COVID-19, dose and duration of treatment with CCS, treatment of ON, follow-up, and treatment outcome. Results A total of 13 studies were included, involving 95 patients and 159 joints. Time between the diagnosis of COVID-19 and the onset of symptoms related to ON was 16 weeks on average. Time between the onset of symptoms and the MRI was 6 weeks. An average of 926.4 mg of prednisolone equivalent per patient were administered. On average, CCS were administered for 20.6 days. Conclusions Patients with a history of COVID-19 infection developed osteonecrosis prematurely and with a lower dose of CCS than usually reported in the literature. Symptoms of osteonecrosis occur within the interval of the period described as Long-COVID. Surgeons should not underestimate the persistence of arthralgia when a history of SARS-CoV-2 infection and use of CCS is reported.

Etiology, pathology, and treatment of osteonecrosis of the femoral head in adolescents: A comprehensive review

Femoral head necrosis is a common refractory disease in orthopedics, and shows a trend of getting younger. The occurrence of femoral head necrosis in adolescents is related to the use of glucocorticoids, autoimmune diseases, trauma, and other factors. Because adolescent patients are in the period of physical development, high activity requirements, and have fertility needs in the future, treatment is relatively difficult. Early artificial joint replacement may have problems such as wear and loosening, so total hip replacement is not the preferred treatment for adolescent patients with femoral head necrosis. This article will elaborate the research progress of femoral head necrosis in adolescents from 3 aspects, and summarize the benefits and side effects of core decompression combined with autologous stem cell transplantation in the treatment of early femoral head necrosis, so as to provide clinical ideas for the treatment of femoral head necrosis in adolescents.

A nomogram for predicting the probability of femoral head collapse in convalescent SARS patients with glucocorticoid-induced osteonecrosis of the femoral head: an 18-year population-based retrospective cohort study

Background

This study aimed to develop a nomogram capable of predicting the probability of femoral head collapse based on an 18-year follow-up cohort of convalescent severe acute respiratory syndrome (SARS) patients with glucocorticoid-induced osteonecrosis of the femoral head (ONFH).

Methods

Data on the natural history of 120 patients (205 hips) who underwent glucocorticoid-induced ONFH at China-Japan Friendship Hospital (CJFH) in 2003 were retrospectively collected. Follow-up was conducted from June 2003 to October 2021. A nomogram was developed in a training cohort and validated in another cohort.

Results

A total of 205 hips were included for analysis, with 143 hips in the training cohorts and 62 hips in the validation cohorts. After 18 years of follow-up, 53 femoral heads collapsed, while 152 femoral heads spontaneously repaired to some extent (necrotic areas reduced or vanished). Following multivariate regression analysis, the Association Research Circulation Osseous (ARCO) staging, necrosis index (NI), and CJFH Classification were entered into the nomogram. The nomogram showed robust discrimination, with an AUC of 0.907 (95% CI: 0.85-0.96). The calibration curves showed an agreement between the probability as predicted by the nomogram and the actual probability. Application of the nomogram in the validation cohort also yielded good discrimination (AUC, 0.876, 95% CI: 0.7751-0.9761) and calibration.

Conclusion

The nomogram successfully predicted femoral head collapse in glucocorticoid-induced ONFH. With the nomogram, the prognosis for an individual patient with glucocorticoid-induced ONFH can be determined, which can lead to a rational therapeutic choice.

Dose-Response Meta-Analysis of Corticosteroid Effects in SARS Outbreak: A Model for Risk Stratification and Screening Strategy for Osteonecrosis of Femoral Head Post-Corticosteroid Therapy for COVID-19

Corticosteroids (CS) have been used in the management regimens for COVID-19 disease to mitigate the cytokine storm and ill effects of the pulmonary inflammatory cascade. With the rampant use of CS, clinicians started reporting the occurrence of osteonecrosis of the femoral head (OFH). In this systematic review, we aim to analyze the literature and identify the definitive cumulative dose and duration of CS needed for the development of OFH based on the SARS model and generate a risk-based screening recommendation for OFH in convalescent COVID-19 patients to facilitate early identification and management. An electronic database search was conducted until December 2022 in PubMed, Web of Science, Embase, and CNKI (China Knowledge Resource Integrated Database). Studies involving CS therapy and osteonecrosis data in SARS patients were included. Three authors independently extracted the data from the included studies and a dose-response meta-analysis was performed for various doses and duration of CS utilized in the included studies. We selected 12 articles with 1728 patients in the analysis. The mean age was 33.41 (±4.93) years. The mean dosage of CS administered was 4.64 (±4.7) g which was administered for a mean duration of 29.91 (±12.3) days. The risk of osteonecrosis increases at pooled OR of 1.16 (95% CI 1.09-1.23, p < 0.001) per 2.0 g increase in the cumulative dose of CS usage. Similarly, the risk increases at pooled OR of 1.02 (95% CI 1.01-1.03, p < 0.001) per 5 days of increase in the cumulative duration of CS usage. A cumulative dosage of 4 g and a duration of 15 days were determined as the critical cut-off for the non-linear dose-response relationship observed. Appropriate and frequent screening of these individuals at regular intervals would help in the identification of the disease at an early stage in order to treat them appropriately.

Accumulation of Fat Not Responsible for Femoral Head Necrosis, Revealed by Single-Cell RNA Sequencing: A Preliminary Study

The etiology of osteonecrosis of the femoral head (ONFH) is not yet fully understood. However, ONFH is a common disease with high morbidity, and approximately one-third of cases are caused by glucocorticoids. We performed single-cell RNA sequencing of bone marrow to explore the effect of glucocorticoid on ONFH. Bone marrow samples of the proximal femur were extracted from four participants during total hip arthroplasty, including two participants diagnosed with ONFH for systemic lupus erythematosus (SLE) treated with glucocorticoids (the case group) and two participants with femoral neck fracture (the control group). Unbiased transcriptome-wide single-cell RNA sequencing analysis and computational analyses were performed. Seventeen molecularly defined cell types were identified in the studied samples, including significantly dysregulated neutrophils and B cells in the case group. Additionally, fatty acid synthesis and aerobic oxidation were repressed, while fatty acid beta-oxidation was enhanced. Our results also preliminarily clarified the roles of the inflammatory response, substance metabolism, vascular injury, angiogenesis, cell proliferation, apoptosis, and dysregulated coagulation and fibrinolysis in glucocorticoid-induced ONFH. Notably, we list the pathways that were markedly altered in glucocorticoid-induced ONFH with SLE compared with femoral head fracture, as well as their common genes, which are potential early therapeutic targets. Our results provide new insights into the mechanism of glucocorticoid-induced ONFH and present potential clues for effective and functional manipulation of human glucocorticoid-induced ONFH, which could improve patient outcomes.

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.

Musculoskeletal Manifestations of COVID-19: Currently Described Clinical Symptoms and Multimodality Imaging Findings

COVID-19, the clinical syndrome produced by infection with SARS-CoV-2, can result in multisystem organ dysfunction, including respiratory failure and hypercoagulability, which can lead to critical illness and death. Musculoskeletal (MSK) manifestations of COVID-19 are common but have been relatively underreported, possibly because of the severity of manifestations in other organ systems. Additionally, patients who have undergone sedation and who are critically ill are often unable to alert clinicians of their MSK symptoms. Furthermore, some therapeutic measures such as medications and vaccinations can worsen existing MSK symptoms or cause additional symptoms. Symptoms may persist or occur months after the initial infection, known as post-COVID condition or long COVID. As the global experience with COVID-19 and the vaccination effort increases, certain patterns of MSK disease involving the bones, muscles, peripheral nerves, blood vessels, and joints have emerged, many of which are likely related to a hyperinflammatory host response, prothrombotic state, or therapeutic efforts rather than direct viral toxicity. Imaging findings for various COVID-19–related MSK pathologic conditions across a variety of modalities are being recognized, which can be helpful for diagnosis, treatment guidance, and follow-up.

The online slide presentation from the RSNA Annual Meeting is available for this article.

^©RSNA, 2022

A case of completed course multifocal osteonecrosis (MFON) during pregnancy due to primary antiphospholipid syndrome

Osteonecrosis of both shoulders and hips is a rare presentation of primary antiphospholipid syndrome. A female patient aged 23 years old with no systemic diseases has her only complaint which was pain and limitations in both hips followed by both shoulders. Careful detailed history and clinical examination is essential for reaching optimum diagnosis thus good management. MRI for hip and shoulder joints is essential for the diagnosis of osteonecrosis. Exclusion of all causes of secondary osteonecrosis by history, clinical examination, and laboratory studies should be done before diagnosing the rare causes of osteonecrosis or the primary type. Pregnancy is an exacerbation factor for primary osteonecrosis. We recommend that the female patient with primary osteonecrosis should receive prophylactic antithrombotic during pregnancy. In conclusion, exclusion of all secondary causes of osteonecrosis is mandatory to reach an accurate diagnosis.

Double Trouble-COVID-19 and the Widespread Use of Corticosteroids: Are We Staring at an Osteonecrosis Epidemic?

Background

A combination of immune-mediated vascular damage and routine use of systemic corticosteroid (CS) therapy in COVID-19 may significantly increase the risk and burden of osteonecrosis (ON) after COVID-19. This narrative review explores the pathogenesis, risk factors, and possible preventive and early treatment measures for ON in COVID-19.

Methods

For this narrative review, an extensive literature search was performed using the PubMed, Medline, and Science Direct databases from January 2000 to August 2021 for relevant articles on etiopathogenesis, epidemiology, clinical manifestations, and treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) infection and steroid-induced ON (SION).

Results

Pathogenesis of COVID-19, utility of corticosteroids in the treatment of COVID-19, pathogenesis of SION vis-a-vis SARS-CoV infection, associated risk factors, and early diagnosis and treatment of ON following CS therapy of SARS-CoV infection were discussed.

Conclusion

Preliminary data of COVID-19 and similar trends from the SARS 2003 epidemic indicate that the "angiocentric" pathogenesis of SARS-CoV-2 and treatment with high-dose CS may increase the risk of ON in COVID-19 patients. Risk stratification based on CS intake during COVID-19 treatment can help identify subjects at moderate to high-risk for ON where early preventive and follow-up plans can be initiated.

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of genetically modified platelet-derived growth factor-BB over-expressing mesenchymal stromal cells during core decompression for steroid-associated osteonecrosis of the femoral head in rabbits

BACKGROUND

Approximately one third of patients undergoing core decompression (CD) for early-stage osteonecrosis of the femoral head (ONFH) experience progression of the disease, and subsequently require total hip arthroplasty (THA). Thus, identifying adjunctive treatments to optimize bone regeneration during CD is an unmet clinical need. Platelet-derived growth factor (PDGF)-BB plays a central role in cell growth and differentiation. The aim of this study was to characterize mesenchymal stromal cells (MSCs) that were genetically modified to overexpress PDGF-BB (PDGF-BB-MSCs) in vitro and evaluate their therapeutic effect when injected into the bone tunnel at the time of CD in an in vivo rabbit model of steroid-associated ONFH.

METHODS

In vitro studies: Rabbit MSCs were transduced with a lentivirus vector carrying the human PDGF-BB gene under the control of either the cytomegalovirus (CMV) or phosphoglycerate (PGK) promoter. The proliferative rate, PDGF-BB expression level, and osteogenic differentiation capacity of unmodified MSCs, CMV-PDGF-BB-MSCs, and PGK-PDGF-BB-MSCs were assessed. In vivo studies: Twenty-four male New Zealand white rabbits received an intramuscular (IM) injection of methylprednisolone 20 mg/kg. Four weeks later, the rabbits were divided into four groups: the CD group, the hydrogel [HG, (a collagen-alginate mixture)] group, the MSC group, and the PGK-PDGF-BB-MSC group. Eight weeks later, the rabbits were sacrificed, their femurs were harvested, and microCT, mechanical testing, and histological analyses were performed.

RESULTS

In vitro studies: PGK-PDGF-BB-MSCs proliferated more rapidly than unmodified MSCs (P < 0.001) and CMV-PDGF-BB-MSCs (P < 0.05) at days 3 and 7. CMV-PDGF-BB-MSCs demonstrated greater PDGF-BB expression than PGK-PDGF-BB-MSCs (P < 0.01). However, PGK-PDGF-BB-MSCs exhibited greater alkaline phosphatase staining at 14 days (P < 0.01), and osteogenic differentiation at 28 days (P = 0.07) than CMV-PDGF-BB-MSCs. In vivo: The PGK-PDGF-BB-MSC group had a trend towards greater bone mineral density (BMD) than the CD group (P = 0.074). The PGK-PDGF-BB-MSC group demonstrated significantly lower numbers of empty lacunae (P < 0.001), greater osteoclast density (P < 0.01), and greater angiogenesis (P < 0.01) than the other treatment groups.

CONCLUSION

The use of PGK-PDGF-BB-MSCs as an adjunctive treatment with CD may reduce progression of osteonecrosis and enhance bone regeneration and angiogenesis in the treatment of early-stage ONFH.

Evaluation of whole-body modalities for diagnosis of multifocal osteonecrosis-a pilot study

Background

This study aimed to investigate the ability of whole-body bone scintigraphy (WB-BS) in the detection of multifocal osteonecrosis (ON) compared to whole-body magnetic resonance imaging (WB-MRI) and to clarify the characteristics of patients with multifocal ON among those with ON of the femoral head (ONFH) using WB-MRI.

Methods

Forty-six patients who had symptomatic ONFH and underwent surgery in our hospital from April 2019 to October 2020 were included in the study. Data on patient demographics, including age, sex, body mass index (BMI), history of corticosteroid intake, alcohol abuse, smoking, and symptomatic joints, were collected from their medical records. All patients underwent WB-MRI and WB-BS before surgery.

Results

The agreement in the detection of ON by WB-MRI vs the uptake lesions by WB-BS in the hip joints was moderate (κ = 0.584), while that in other joints was low (κ < 0.40). Among the 152 joints with ON detected by WB-MRI, 92 joints (60.5%) were symptomatic, and 60 joints (39.5%) were asymptomatic. Twelve out of the 46 (26.0%) patients had multifocal (three or more distinct anatomical sites) ON. Nonetheless, while WB-BS detected symptomatic ON detected by WB-MRI as uptake lesions in 82.6% (76/92) of the joints, asymptomatic ON detected by WB-MRI was detected as uptake lesions in 21.7% (13/60) of the joints. All patients with multifocal ON had a history of steroid therapy, which was significantly higher than that in patients with oligofocal ON (P = 0.035). The patients with a hematologic disease had multifocal ON at a higher rate (P = 0.015).

Conclusions

It might be difficult for WB-BS to detect the asymptomatic ON detected by WB-MRI compared to symptomatic ON. Considering the cost, examination time, and radiation exposure, WB-MRI might be useful for evaluating multifocal ON. Larger longitudinal studies evaluating the benefits of WB-MRI for detecting the risk factors for multifocal ON are required.

Effects of Short-Term Low-Dose Glucocorticoids for Patients with Mild COVID-19

OBJECTIVES

To evaluate the role of short-term low-dose glucocorticoids in mild COVID-19 patients.

METHODS

We conducted a retrospective, cross-sectional, single-center study in Kunming, China. A total of 33 mild COVID-19 cases were divided into two treatment groups (with and without glucocorticoids, methylprednisolone, were used in this setting), and the absolute value of peripheral blood lymphocyte count; CD3+, CD4+, and CD8+ T cell counts; and the time to achieve negative transformation of a nucleic acid pharyngeal swab were recorded. Peripheral blood lymphocyte and T cell counts were compared between the treatment group and 25 healthy individuals. At the point of time when there was a 50% accumulation conversion rate (positive to negative nucleic acid on pharyngeal swab), and the nucleic acid turned negative in half of the patients in two groups, the peripheral blood lymphocyte and T cell counts were compared between treatment groups.

RESULTS

The mean cumulative time for the 50% negative conversion rate of the nucleic acid in the pharyngeal swab was 17.7 ± 5.1 days and 13.9 ± 5.4 days in the glucocorticoid group and the nonglucocorticoid group, respectively. The absolute peripheral blood lymphocyte count and the T cell subset count in the glucocorticoid group were lower than those in the nonglucocorticoid group. When the nucleic acid turned negative in half of the patients, the absolute value of peripheral blood lymphocyte count and CD4+ T cells of the glucocorticoid group and the nonglucocorticoid group was not significantly different; the CD3+ and CD8+ T cells in the glucocorticoid group were lower than those in the nonglucocorticoid group. The absolute peripheral blood lymphocyte count, CD3+ T cells, and CD4+ T cells in the glucocorticoid group were lower than those of the healthy group during the whole disease period, and CD8+ T cells returned to normal at 19-21 days of the disease period. There was no significant difference between the nonglucocorticoid group and the healthy group for absolute peripheral blood lymphocyte and CD8+ T cells; moreover, CD3+ T cells and CD4+ T cells were lower in the nonglucocorticoid group than those in the healthy group from the day of admission to the 18th day and returned to normal at the period of 19-21 days. The absolute peripheral lymphocyte count (P = 0.048, effect size d = 0.727) and T cell subset count (CD3: P = 0.042, effect size d = 0.655; CD4: P < 0.01, effect size d = 0.599; and CD8: P = 0.034, effect size d = 0.550) in the nonglucocorticoid group were higher than those in the glucocorticoid group, and the difference between the groups was statistically significant.

CONCLUSIONS

This study found that the use of short-term, low-dose glucocorticoids does not negatively influence the clinical outcome, without affecting the final clearance of viral nucleic acid in mild COVID-19 patients.

IL-15 deficiency alleviates steroid-induced osteonecrosis of the femoral head by impact osteoclasts via RANKL-RANK-OPG system

Background

Whether IL-15 is involved in the development of steroid-induced osteonecrosis of the femoral head (ONFH) is investigated.

Methods

C57BL/6 J and l15^−/−mice were injected with methylprednisolone to induce wide type osteonecrosis (WT ON) and IL-15 deficiency osteonecrosis (IL-15^−/− ON). Hematoxylin-Eosin (H&E) staining and micro-computed tomography (micro-CT) scanning was used to detect the microstructure. The differentiation and formation of osteoclasts were determined with colony-forming unit-granulocyte macrophages (CFU-GM), colony-forming unit-macrophage/mononuclear (CFU-M) per tibia, and tartrate-resistant acid phosphatase (TRACP or TRAP) positive cells. Serum interleukin (IL)-15, osteocalcin, bone alkaline phosphatase (BAP), bone Gla protein (BGP), and TRACP were assayed with enzyme-linked immunosorbent assay (ELISA). The receptor activator of nuclear factor-κB (RANK), RANK ligand (RANKL), and osteoprotegerin (OPG) in the femoral heads were detected by Western blot. CD34 staining was performed to detect microvascular density.

Results

IL-15 secretion was increased in the femoral heads and the serum of steroid-induced ONFH mice. IL-15 deficiency may lead to up-regulated vessel remodeling, improved microstructure, and up-regulated serum osteocalcin, BAP, and BGP secretion. Both the expression of RANKL/RANK/OPG and osteoclast differentiation and formation can be down-regulated by IL-15 deficiency.

Conclusion

IL-15 deficiency alleviates steroid-induced ONFH by impact osteoclasts via RANKL-RANK-OPG system.

Effectiveness of glucocorticoid therapy in patients with severe coronavirus disease 2019: protocol of a randomized controlled trial

BACKGROUND

At the end of 2019, a novel coronavirus outbreak causative organism has been subsequently designated the 2019 novel coronavirus (2019-nCoV). The effectiveness of adjunctive glucocorticoid therapy in the management of 2019-nCoV-infected patients with severe lower respiratory tract infections is not clear, and warrants further investigation.

METHODS

The present study will be conducted as an open-labeled, randomized, controlled trial. We will enrol 48 subjects from Chongqing Public Health Medical Center. Each eligible subject will be assigned to an intervention group (methylprednisolone via intravenous injection at a dose of 1-2 mg/kg/day for 3 days) or a control group (no glucocorticoid use) randomly, at a 1:1 ratio. Subjects in both groups will be invited for 28 days of follow-up which will be scheduled at four consecutive visit points. We will use the clinical improvement rate as our primary endpoint. Secondary endpoints include the timing of clinical improvement after intervention, duration of mechanical ventilation, duration of hospitalization, overall incidence of adverse events, as well as rate of adverse events at each visit, and mortality at 2 and 4 weeks.

DISCUSSION

The present coronavirus outbreak is the third serious global coronavirus outbreak in the past two decades. Oral and parenteral glucocorticoids have been used in the management of severe respiratory symptoms in coronavirus-infected patients in the past. However, there remains no definitive evidence in the literature for or against the utilization of systemic glucocorticoids in seriously ill patients with coronavirus-related severe respiratory disease, or indeed in other types of severe respiratory disease. In this study, we hope to discover evidence either supporting or opposing the systemic therapeutic administration of glucocorticoids in patients with severe coronavirus disease 2019.

TRIAL REGISTRATION

ClinicalTrials.gov, ChiCTR2000029386, http://www.chictr.org.cn/showproj.aspx?proj=48777.

Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study

The most severe sequelae after rehabilitation from SARS are femoral head necrosis and pulmonary fibrosis. We performed a 15-year follow-up on the lung and bone conditions of SARS patients. We evaluated the recovery from lung damage and femoral head necrosis in an observational cohort study of SARS patients using pulmonary CT scans, hip joint MRI examinations, pulmonary function tests and hip joint function questionnaires. Eighty medical staff contracted SARS in 2003. Two patients died of SARS, and 78 were enrolled in this study from August 2003 to March 2018. Seventy-one patients completed the 15-year follow-up. The percentage of pulmonary lesions on CT scans diminished from 2003 (9.40 ± 7.83)% to 2004 (3.20 ± 4.78)% (P < 0.001) and remained stable thereafter until 2018 (4.60 ± 6.37)%. Between 2006 and 2018, the proportion of patients with interstitial changes who had improved pulmonary function was lower than that of patients without lesions, as demonstrated by the one-second ratio (FEV₁/FVC%, t = 2.21, P = 0.04) and mid-flow of maximum expiration (FEF_25%–75%, t = 2.76, P = 0.01). The volume of femoral head necrosis decreased significantly from 2003 (38.83 ± 21.01)% to 2005 (30.38 ± 20.23)% (P = 0.000 2), then declined slowly from 2005 to 2013 (28.99 ± 20.59)% and plateaued until 2018 (25.52 ± 15.51)%. Pulmonary interstitial damage and functional decline caused by SARS mostly recovered, with a greater extent of recovery within 2 years after rehabilitation. Femoral head necrosis induced by large doses of steroid pulse therapy in SARS patients was not progressive and was partially reversible.

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

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

Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment

Osteonecrosis of the femoral head is a disabling pathology affecting a young population (average age at treatment, 33 to 38 years) and is the most important cause of total hip arthroplasty in this population. It reflects the endpoint of various disease processes that result in a decrease of the femoral head blood flow.The physiopathology reflects an alteration of the vascularization of the fine blood vessels irrigating the anterior and superior part of the femoral head. This zone of necrosis is the source of the loss of joint congruence that leads to premature wear of the hip.Several different types of medication have been developed to reverse the process of ischemia and/or restore the vascularization of the femoral head. There is no consensus yet on a particular treatment.The surgical treatments aim to preserve the joint as far as the diagnosis could be made before the appearance of a zone of necrosis and the loss of joint congruence. They consist of bone marrow decompressions, osteotomies around the hip, vascular or non-vascular grafts.Future therapies include the use of biologically active molecules as well as implants impregnated with biologically active tissue. Cite this article: EFORT Open Rev 2019;4:85-97. DOI: 10.1302/2058-5241.4.180036.

Corticosteroid-induced Osteonecrosis of the Femoral Head: Detection, Diagnosis, and Treatment in Earlier Stages

Objective:

This review aimed to provide a current recommendation to multidisciplinary physicians for early detection, diagnosis, and treatment of corticosteroid-induced osteonecrosis of the femoral head (ONFH) based on a comprehensive analysis of the clinical literature.

Data Sources:

For the purpose of collecting potentially eligible articles, we searched for articles in the PubMed, Cochrane Library, Embase, and CNKI databases up to February 2017, using the following key words: “corticosteroid”, “osteonecrosis of the femoral head”, “risk factors”, “diagnosis”, “prognosis”, and “treatment”.

Study Selection:

Articles on relationships between corticosteroid and ONFH were selected for this review. Articles on the diagnosis, prognosis, and intervention of earlier-stage ONFH were also reviewed.

Results:

The incidence of corticosteroid-induced ONFH was associated with high doses of corticosteroids, and underlying diseases in certain predisposed individuals mainly occurred in the first 3 months of corticosteroid prescription. The enhanced awareness and minimized exposure to the established risk factors and earlier definitive diagnosis are essential for the success of joint preservation. When following up patients with ONFH, treatment should be started if necessary. Surgical treatment yielded better results than conservative therapy in earlier-stage ONFH. The ideal purpose of earlier intervention and treatment is permanent preservation of the femoral head without physical restrictions in daily living.

Conclusions:

Clinicians should enhance their precaution awareness of corticosteroid-induced ONFH. For high-risk patients, regular follow-up is very important in the 1^st year after high-dose prescription of corticosteroids. Patients with suspected ONFH should be referred to orthopedists for diagnosis and treatment in its earlier stage to preserve the joint.

Combined pharmacotherapy for osteonecrosis of the femoral head after severe acute respiratory syndrome and interstitial pneumonia: two and a half to fourteen year follow-up

PURPOSE

The purpose of this study was to retrospectively analyze the clinical, functional, and radiological outcomes of combined pharmacotherapy to ONFH after high-dose corticosteroid therapy.

METHOD

From August 2003 to June 2015, five patients (ten hips) of ONFH in ARCO stage I, after SARS and Interstitial pneumonia, were treated by combined pharmacotherapy. Lipo-prostaglandin E₁ 10 μg iv Bid × 28 days, enoxaparin 6000 iu H QD × 12 weeks, alendronate sodium tablet 10 mg QD × 1 year. The patients were fully weight-bearing following completion of the follow-up.

RESULT

For these five patients (ten hips), Harris score was 100 from the diagnosis to final follow-up time. Radiologic findings show no signs of collapse, necrotic focus was repaired, and ARCO stages were changed from I_C into II_B.

CONCLUSION

This combined pharmacotherapy has promising treatment results for delaying or preventing collapse of ONFH in ARCO stage I.

Serum glycosylation characterization of osteonecrosis of the femoral head by mass spectrometry

Osteonecrosis of the femoral head is a recalcitrant and paralyzing disease often discovered in the end stage at the time of diagnosis, which is often performed by physical examination and diagnostic imaging. Osteonecrosis of the femoral head is typically caused by trauma or long-term steroid use. There are over 30 million patients in the US taking steroids, and roughly 40% will develop osteonecrosis of the femoral head. However, the exact pathophysiological process is not well understood. This study aims to examine the alteration in serum glycosylation of osteonecrosis of the femoral head using the state-of-the-art analytical tools to provide more chemical data for pathophysiology research and possibly biomarker discovery. A training set containing 27 serum samples from steroid-induced osteonecrosis of the femoral head patients and 25 from gender- and age-matched controls was collected and analyzed. Glycosylation of whole serum and site-specific glycosylation of immunoglobulins are characterized using electrospray ionization-Q-time of flight and electrospray ionization-Triple-Quadruple via multiple reaction monitoring, respectively. The whole serum glycosylation analysis yielded 14 N-glycan compositions and multiple reaction monitoring yielded eight glycopeptides that were altered between cases and controls with statistical significance. The increase of nonsialylated, nonfucosylated N-glycans and decrease of fucosylated N-glycans are associated with the development of osteonecrosis of the femoral head. Glycosylation is a posttranslational protein modification and is apparently affected by osteonecrosis of the femoral head. Future studies with a larger cohort and patients from earlier stage will be performed to assess these potential markers' value in disease onset.

Correlation Between Steroid-Induced Osteonecrosis of The Femoral Head and Hepatic CYP3A Activity: A Systematic Review and Meta-Analysis

BACKGROUND

Steroid-induced osteonecrosis of the femoral head (ONFH) in young adults is a challenging disorder that can impairs the quality of life of a patient. The disease also leads to frequent occurrences of collapse of the femoral head and resultant dysfunction of the hip joint. In recent years, some scholars have studied steroid-induced lipid metabolism disorder and achieved the effect of steroid-induced ONFH treatment. This study aims to review the investigations on the hepatic CYP3A (cytochrome P4503A enzyme) genetic polymorphisms in steroid-induced ONFH patients. We then further explore its activity correlation with the development of steroid-induced ONFH in a rabbit model.

METHODS

A systematic literature search of articles was conducted in PubMed, Web of Science, Google Scholar, Springerlink, and the Chinese National Knowledge Infrastructure database up to February 2017. Twelve relevant articles were retrieved. The odds ratios, standard mean difference, and 95% confidence intervals were calculated to assess the effect of hepatic CYP3A activity on the rabbit model with steroid-induced ONFH. Fixed-effects and random-effects models were used to analyze the heterogeneity. Begg's funnel plot was used to assess publication bias.

RESULTS

High hepatic CYP3A activity significantly decreased the risk for steroid-induced ONFH in the rabbit model (p <. 05). The CYP3A gene may be potentially associated with increased risk of steroid-induced ONFH in the human allele model.

CONCLUSION

The study suggests that high hepatic CYP3A activity decreases the risk of steroid-induced ONFH.

[A summary of hip-preservation surgery based on peri-collapse stage of osteonecrosis of femoral head]

Objective

To summarize surgical procedures of hip-preservation based on peri-collapse stage of osteonecrosis of the femoral head (ONFH).

Methods

The basic points of peri-collapse stage theory was expounded. The related literature on surgical procedures was summarized and analyzed based on the theory.

Results

Surgical procedures of hip-preservation tend to emphasize on mechanical repair, giving consideration to biological repair. It is consistent with the essence of peri-collapse stage theory, which attaches great importance to biomechanical stability.

Conclusion

Peri-collapse stage theory has a guiding significance to the choice of surgical timing and approach, and it is one of the important theoretical basis for hip-preservation treatment.

Steroid therapy and the risk of osteonecrosis in SARS patients: a dose-response meta-analysis

This meta-analysis synthesized current evidence from 10 trials to evaluate the association between steroid therapy and osteonecrosis incidence in patients with severe acute respiratory syndrome (SARS). Our results suggest that higher cumulative doses and longer treatment durations of steroids are more likely to lead to the development of osteonecrosis in SARS patients.

INTRODUCTION

The link between steroid treatment and the risk of osteonecrosis in SARS patients remains unknown. The present meta-analysis aimed to examine the dose-response association between steroid therapy and osteonecrosis incidence in SARS patients. The sex differences in the development of steroid-induced osteonecrosis were also examined.

METHODS

We searched PubMed, Web of Science, CNKI, and WANFANG for studies that involved steroid therapy and reported osteonecrosis data in SARS patients. Two authors independently extracted the data from the individual studies, and the rate ratio (RR) of osteonecrosis was calculated using random-effect models.

RESULTS

Ten studies with 1137 recovered SARS patients met the inclusion criteria. Close relationships between osteonecrosis incidence and both the cumulative dose and treatment duration of steroids were observed. The summary RR of osteonecrosis was 1.57 (95% confidence interval (CI) 1.30-1.89, p < 0.001) per 5.0 g increase in the cumulative dose of steroids and was 1.29 (95% CI 1.09-1.53, p = 0.003) for each 10-day increment of increase in treatment duration. The relationship was non-linear (p _non-linear < 0.001 and p _non-linear = 0.022). There were no significant differences in the risk of developing osteonecrosis between the male and female patients (RR 0.01, 95% CI -0.03 to 0.06, p = 0.582).

CONCLUSIONS

SARS patients who received higher cumulative doses and longer treatment durations of steroids were more likely to develop osteonecrosis, and there were no sex differences in this dose-dependent side effect. Our findings suggest that it is important to reduce osteonecrosis risk by modifying the cumulative dose and the treatment duration of steroids in SARS patients.

Nontraumatic Osteonecrosis of the Distal Tibia: A Case Presentation and Review of the Literature

Osteonecrosis, although commonly occurring in the hip, can also affect the leg and foot. In the foot, it most commonly occurs in the talus. The incidence of osteonecrosis occurring in the tibia is relatively rare. We report a case of a woman who presented to our clinic with ankle pain that was idiopathic in nature. Subsequent magnetic resonance imaging showed findings consistent with osteonecrosis of the bilateral distal tibias and several other lesions located in the shoulder, hip, and calcaneus. The present report also serves as a review of both etiology and treatment of osteonecrosis as it relates to the lower extremity.

Bilateral Osteonecrosis of the Femoral Head During Pregnancy Following Two Corticosteroid Injections: A Case Report and Review of the Literature

Osteonecrosis of the femoral head during pregnancy, or shortly thereafter, is a rare clinical problem. Little is known about pregnancy as an etiological factor for femoral head osteonecrosis with only 40 reported cases in the literature. Furthermore, single or dual dose steroid-induced multifocal osteonecrosis is a controversial topic with only a handful of published cases. We present a case of a 34-year-old female with bilateral femoral head osteonecrosis that developed during the peripartum period. She received two large intramuscular injections of steroids for fetal lung maturity because early delivery was required as a result of eclampsia. She underwent total arthroplasty of the left hip due to unremitting pain and functional disability, which achieved good clinical results--relieving her pain and improving her range of motion. Literature is scarce with regard to single or dual dose steroid-induced osteonecrosis of the hip as well as pregnancy as a general etiologic factor. This case highlights the need for high clinical suspicion of osteonecrosis as a cause of postpartum hip pain.

A steroid-induced bilateral avascular necrosis of the femoral head in an underage patient affected by multiple sclerosis

Patients affected by Multiple Sclerosis are often treated by pulsed intravenous corticosteroids to manage acute relapses with positive outcomes. The intravenous administration is frequently associated to avascular necrosis of several bones, particularly the femur. The present report regards a case of an underage MS patient with a bilateral ANFH secondary to pulsed administrations of steroids, managed by a conservative approach on a hip, and by a novel surgical technique on the contralateral side.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment with anti-C5a antibody improves the outcome of H7N9 virus infection in African green monkeys

This study demonstrated that aberrant complement activation plays an important role in pathogenesis of acute lung injury induced by influenza A(H7N9) virus infection and that anti-C5a antibody treatment might be an effective new strategy for acute viral pneumonia.

Background. Patients infected with influenza A(H7N9) virus present with acute lung injury (ALI) that is due to severe pneumonia and systemic inflammation. It is often fatal because there are few effective treatment options. Complement activation has been implicated in the pathogenesis of virus-induced lung injury; therefore, we investigated the effect of targeted complement inhibition on ALI induced by H7N9 virus infection.

Methods. A novel neutralizing specific antihuman C5a antibody (IFX-1) was used. This antibody blocked the ability of C5a to induce granulocytes to express CD11b while not affecting the ability of C5b to form the membrane attack complex. African green monkeys were inoculated with H7N9 virus and treated intravenously with IFX-1.

Results. The virus infection led to intense ALI and systemic inflammatory response syndrome (SIRS) in association with excessive complement activation. Anti-C5a treatment in H7N9-infected monkeys substantially attenuated ALI: It markedly reduced the lung histopathological injury and decreased the lung infiltration of macrophages and neutrophils. Moreover, the treatment decreased the intensity of SIRS; the body temperature changes were minimal and the plasma levels of inflammatory mediators were markedly reduced. The treatments also significantly decreased the virus titers in the infected lungs.

Conclusions. Antihuman C5a antibody treatment remarkably reduced the ALI and systemic inflammation induced by H7N9 virus infection. Complement inhibition may be a promising adjunctive therapy for severe viral pneumonia.

The influence of age, gender and treatment with steroids on the incidence of osteonecrosis of the femoral head during the management of severe acute respiratory syndrome: a retrospective study

Corticosteroid use has been implicated in the development of osteonecrosis of the femoral head (ONFH). The exact mechanism and predisposing factors such as age, gender, dosage, type and combination of steroid treatment remain controversial. Between March and July 2003, a total of 539 patients with severe acute respiratory syndrome (SARS) were treated with five different types of steroid. There were 129 men (24%) and 410 women (76%) with a mean age of 33.7 years (21 to 59). Routine screening was undertaken with radiographs, MRI and/or CT to determine the incidence of ONFH. Of the 129 male patients with SARS, 51 (39.5%) were diagnosed as suffering from ONFH, compared with only 79 of 410 female patients (19.3%). The incidence of ONFH in the patients aged between 20 and 49 years was much higher than that of the group aged between 50 and 59 years (25.9% (127 of 491) versus 6.3% (3 of 48); p = 0.018). The incidence of ONFH in patients receiving one type of steroid was 12.5% (21 of 168), which was much lower than patients receiving two different types (28.6%; 96 of 336) or three different types of steroid (37.1%; 13 of 35).

Inflammatory bowel disease, high-dose steroids, osteoporosis, or an oncological etiology for a pathological femoral neck fracture in a young adult: a case report

Femoral neck fractures occur in approximately 6,000 of young adults annually (ages 18-49) (1). Of these, a high-energy traumatic event is the typical cause. Although medications and chronic diseases have been implicated as confounding causes of hip fractures, clinicians should have a high index of suspicion for an oncologic etiology of hip fractures occurring in young patients without an inciting traumatic event.

Clinical management and infection control of SARS: lessons learned

The outbreak of severe acute respiratory syndrome (SARS) in 2003 was the first emergence of an important human pathogen in the 21st century. Responding to the epidemic provided clinicians with extensive experience in diagnosing and treating a novel respiratory viral disease. In this article, we review the experience of the SARS epidemic, focusing on measures taken to identify and isolate patients, prevent the transmission of infection to healthcare workers and develop effective therapies. Lessons learned from the SARS epidemic will be especially important in responding to the current emergence of another highly pathogenic human coronavirus, the agent of Middle East respiratory syndrome (MERS), and to the recently emerging H7N9 influenza A virus in China. This paper forms part of a symposium in Antiviral Research on "From SARS to MERS: 10years of research on highly pathogenic human coronaviruses."

Knee pain in patients with cancer after chemotherapy, radiotherapy, and bone marrow transplantation

The causes of knee pain in patients with cancer with are different from those without cancer, and the purpose of this study was to evaluate these differences. Thirty-six patients with cancer who had knee pain who had undergone 1 or more modalities of treatment, including chemotherapy, radiotherapy, and bone marrow transplant, for a primary diagnosis of cancer were compared with a cohort of 40 patients without cancer who had knee pain. All patients were evaluated clinically and underwent radiographic examination, and some underwent computed tomography or magnetic resonance imaging examination. Among patients with a primary diagnosis of cancer, the most common diagnosis was lymphoma (n=10), and the most common causes of knee pain were avascular necrosis of bone, osteoarthritis, insufficiency fractures, and septic arthritis. In 5 patients, the classical signs of a septic knee were not present. Other causes of knee pain included meniscus tear and anterior cruciate ligament rupture with instability. The most common diagnosis in patients without cancer was osteoarthritis of the knee. No patient without cancer was diagnosed with avascular necrosis, metastatic lesion, or insufficiency fracture. Two patients without cancer were diagnosed with septic arthritis of the knee. This study showed that the causes of knee pain in patients with cancer are different from those without cancer. Septic arthritis may present without the classical clinical signs in patients with cancer, and a high index of suspicion should be maintained for it.

Osteonecrosis of the femoral head in SARS patients: seven years later

This study is aimed to explore the progression of osteonecrosis of the femoral head (OFNH) in severe acute respiratory syndrome patients 7 years after steroid administration and to analyze factors affecting the prognosis. One-hundred and ninety hips in 117 patients with more than 7 years of follow-up were studied. The prevalence of progression to symptoms and collapse was determined. The total dose of steroid, gender, age, stage, lesion location, volume of necrosis, viable lateral column and bone marrow edema were analyzed and correlated with progression. During the 7 years of follow-up, 66 hips progressed to symptoms, 50 hips collapsed and 10 hips showed complete regression. Fifty-seven hips (86.36 %) caused pain and 32 (64.00 %) collapsed within 3 years of steroid administration. The lesion was relatively larger, and there was relatively less viable lateral column in hips that exhibited symptoms or collapsed. Mechanical failure of the necrotic segment of bone principally occurred within 3 years after the administration of steroids. Larger lesions and less viable lateral column were the main risk factors for progression. Small ONFH lesions seldom collapsed.

Bilateral osteonecrosis of the navicular and medial cuneiform in a patient with systemic lupus erythematosus: a case report

INTRODUCTION

Atraumatic avascular necrosis (AVN) is an unusual pathology to the foot. Risk factors include the use of corticosteroids, smoking, alcohol, rheumatologic disorders, hematologic disorders, and metabolic disorders. To the authors' knowledge, this study presents the first case of bilateral atraumatic AVN to the navicular and medial cuneiform in a patient with systemic lupus erythamatosus (SLE).

CASE DESCRIPTION

A 40-year-old man presented with a past medical history of SLE in which he developed AVN of the tarsal navicular and medial cuneiform. This occurred first on the subject's right foot and then while recovering from surgical intervention, on his left foot. Talonaviculocuneiform arthrodesis was performed with the use of distal tibial autograft on both extremities. The subject's American Orthopaedic Foot and Ankle Society midfoot score improved from 34 to 80 at 21 months on the right and 37 to 90 at 15 months to the left.

DISCUSSION

Patients with SLE carry a significant risk of developing AVN. Comorbidities such as vasculitis, corticosteroid use, cytotoxic medication, and peripheral neuropathy are known risk factors in the development of AVN. Unusual features such as multifocal AVN and unusual anatomic locations can occur with SLE. AVN of the foot is generally treated with surgical intervention. Treatments such as core decompression, open reduction and internal fixation, and arthrodesis have been recommended based on the symptoms and presentation.

CONCLUSION

The authors present a very rare presentation of bilateral osteonecrosis of the tarsal navicular and first cuneiform in a patient with SLE. The patient was treated with bilateral talonaviculocuneiform arthrodesis. The patient demonstrated considerable improvement to both extremities.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Osteonecrosis in patients after severe acute respiratory syndrome (SARS): possible role of anticardiolipin antibodies

OBJECTIVES

This study examined the anticardiolipin antibodies in post-SARS (severe acute respiratory syndrome) osteonecrosis patients to investigate the etiology of post-SARS osteonecrosis, and to eventually provide valuable information for the early diagnosis of nontraumatic osteonecrosis and for the susceptible population screening.

METHODS

This study recruited 62 post-SARS osteonecrosis patients and 52 age- and gender-matched healthy controls. Fasting blood samples were collected from all the subjects through cubital veins. Immunoglobulins A, G and M (IgA, G and M) types of anticardiolipin antibodies were examined by enzyme-linked immunosorbent assay. The routine examinations of prothrombin time, thrombin time, prothrombin activity, and international normalized ratio were also performed.

RESULTS

There were 21 of 62 post-SARS osteonecrosis patients (33.9%) who showed at least one type of anticardiolipin antibodies. The titers of specific IgA, IgG, and IgM were 11.33 +/- 11.209 APL, 5.127 +/- 5.927 GPL, and 17.821 +/- 10.606 MPL, respectively. There were only 4 of 52 subjects in the control group (7.7%) who showed positive anticardiolipin antibody with titers of IgA at 10.702 +/- 3.126 APL, IgG at 5.184 +/- 4.780 GPL, and IgM at 14.684 +/- 5.516 MPL. There were significant differences between the 2 groups confirmed by t-Test and chi(2) test (P < 0.05), while no significant differences were observed in prothrombin time, thrombin time, prothrombin activity, and international normalized ratio results between the 2 groups.

CONCLUSIONS

The incidences of anticardiolipin antibodies were increased in the post-SARS osteonecrosis patients and anticardiolipin antibodies may play a role in the pathogenesis of post-SARS osteonecrosis.

Symptomatic, steroid-induced, multifocal diaphyseal osteonecrosis in a patient with multiple sclerosis

There is a well-established link between the development of osteonecrosis and steroid administration. Diaphyseal osteonecrosis is rare and, when present, frequently asymptomatic and detected radiologically. We present a case of symptomatic, multifocal, diaphyseal osteonecrosis in a woman receiving pulsed corticosteroids for symptom control of multiple sclerosis (MS). She was investigated for knee pain, which could have been attributed to her primary disease, and magnetic resonance imaging (MRI) revealed bone infarcts within the femur, tibia and talus. She underwent successful intra-medullary reaming to the diaphyseal infarcts. This case highlights the importance of investigating musculoskeletal pain in patients with MS, receiving corticosteroids.