Pharmacological management of aseptic osteonecrosis in children

The Use of Iloprost in the Treatment of Bone Marrow Edema Syndrome of the Proximal Femur: A Review and Meta-Analysis

Objective: The aim of this meta-analysis was to investigate the impact of intravenous iloprost therapy on pain, function, edema changes, and follow-up surgery in bone marrow edema syndrome of the proximal femur. Methods: A systematic literature search up to May 2022 was performed to find relevant papers that made a statement about the outcome of intravenous iloprost therapy alone. Factors such as the Visual Analog Scale (VAS), Harris Hip Score (HHS), edema reduction, and follow-up interventions were considered. These were compared using Forest plots. Results: In 11 studies, 190 proximal femora with bone marrow edema syndrome that received intravenous iloprost therapy without further therapeutic intravenous or surgical intervention such as core decompression were studied. There was a significant mean improvement in VAS by 3.3 cm (2.07−4.5 cm) (p < 0.001) and HHS by 24.36 points (18.23−30.49) (p < 0.001) 3−6 months after receiving iloprost therapy. Only in 9.3% of cases (1.1−24.3%) did no clinical or radiological improvement occur. Conclusions: It could be shown that the existing publications support intravenous therapy with iloprost in patients with bone marrow edema syndrome and result in good clinical outcomes.

Combined with Bone Marrow-Derived Cells and rhBMP-2 for Osteonecrosis after Femoral Neck Fractures in Children and Adolescents: A case series

Osteonecrosis of the femoral head (ONFH) following femoral neck fractures is a rare, yet severe, disorder in children and adolescents. This study evaluated the effectiveness of core decompression (CD) combined with implantation of bone marrow-derived cells (BMDC) and rhBMP-2 for osteonecrosis of femoral head (ONFH) after femoral neck fractures in children and adolescents. This study included 51 patients, aged 11.4-18.1 years, with ARCO stages I-III ONFH after femoral neck fractures between 2004 and 2010. The hips were divided into two groups based on whether the lateral pillar of the femoral head (LPFH) was preserved: LPFH and non-LPFH groups. All patients were followed up clinically and radiographically for a minimum of 5 years. 44 patients (86.3%) had improved clinical outcome. Radiologically, 9 of the 51 hips (17.6%) exhibited collapse onset or progression of the femoral head or narrowing of the hip joint space, and one patient in the non-LPFH group required hip arthroplasty due to the worsened syndrome. The technique provided an effective therapeutic option for children and adolescents with ONFH following femoral neck fractures. It relieves hip pain and prevents the progression of osteonecrosis in young patients lasting more than 5 years after surgery.

[Bone marrow edema and atraumatic necrosis of the femoral head : Therapy]

BACKGROUND

An increase in interstitial bony fluid occurs in bone-marrow edema (BME). The exact pathogenetic processes still remain unknown. BME is an unspecific finding that can occur on its own or accompany multiple diseases and pathologies.

GOAL

Literature review and presentation of new guidelines.

MATERIAL AND METHODS

This is a narrative literature review followed by current advice for the therapy of atraumatic osteonecrosis of the hip, based on the recently published S3-guidelines for this disease.

RESULTS AND DISCUSSION

The differentiation of at least 3 different etiologies is proposed (mechanic, reactive and ischemic). Difficult, but important, is the distinction between the mostly painful, but benign entities (BME syndrome, bone bruise) and the progressive pathologies (osteonecrosis, arthritis, CRPS, tumour). Treatment options are dependent on etiology and clinic and can often be symptomatic. Core decompression is the surgical gold standard, leading to immediate pressure relief and therefore reduction in pain. Recently, it was shown that intravenous administration of Iloprost and bisphosphonates are also effective in achieving a reduction of BME and pain, with considerable improvement in the accompanying symptoms. The combination of core decompression and infusion seems to be another possible optimization ofthe therapy, in particular in the treatment of osteonecrosis.

[Aseptic osteonecrosis in children and adolescents]

BACKGROUND

Aseptic osteonecrosis (AO) in children and adolescents has been described in all parts of the skeleton. The disease is presumed to be caused by local blood circulation disorders, the reasons for which are multifactorial and occur more often in times of stronger growth intensity.

DISEASE SEQUELAE

The disease leads to bone catabolism which can affect the epiphyses, metaphyses, apophyses, carpal and tarsal bones of the hands and feet. The more stretched the form alteration of the bone at the end of the diseases is, the earlier arthritic alterations occur due to the incongruence of the corresponding joint partner. If a growth plate is affected, a growth disorder can be the result.

DIAGNOSTICS AND THERAPY

The diagnostics and therapeutic measures are oriented to the site and extent of the disease and the age of the child. For early forms of AO magnetic resonance imaging (MRI) is the imaging method of choice. In recent years the medicinal therapy of AO has been described as an additional option. The disease lasts at least several months up to years and more commonly affects boys than girls with the exception of necrosis of the foot tarsals.

CONCLUSION

The early diagnosis and immediate initiation of adequate therapy which must take the age and stage of the disease into consideration, can reduce a possible joint destruction. Prostaglandin therapy, as an off label use, leads to a reduction of pain and improvement in mobility.

Effect of pentoxifylline on histopathological changes in steroid-induced osteonecrosis of femoral head: experimental study in chicken

PURPOSE

Pentoxifylline (PTX) is a derivative of methylxanthine and is used in peripheral vascular and cerebrovascular diseases for its effect on the regulation of blood circulation. We investigated whether PTX could be beneficial for femoral head osteonecrosis associated with steroid through these effects.

METHODS

Sixty mature Leghorn type chickens were chosen and divided into three groups. The 25 chickens in group A were given a weekly dose of 3 mg/kg/week methylprednisolone acetate intramuscularly. Four chickens in group B died after the first drug injection and were excluded from the study. Therefore, the remaining 21 chickens in group B were additionally given 25 mg/kg/day pentoxifylline intramuscularly, along with the steroid medication as given in group A. The ten chickens in group C were not given any injections, as they were accepted as the control group. After the sacrifice of the animals at week 14, both femoral heads were taken from each animal. The animals which died along the course of the study also underwent pathological examination but were not a part of the statistical analysis.

RESULTS

In this study, steroid induced femoral head osteonecrosis has been experimentally observed in chickens after high doses of corticosteroid therapy. The chickens were given pentoxifylline in order to prevent the effects of steroid on bones and bone marrow. The results showed that chickens are suitable osteonecrosis models, and that steroid causes adipogenesis and necrosis in the bone marrow and the death of the subchondral bone.

CONCLUSIONS

The results of this study hint at the assumption that PTX may have a positive benefit on ONFH. PTX seems to minimise the effects of the steroid and reduce the incidence of ONFH.

Possible beneficial effect of bisphosphonates in osteonecrosis of the knee

Osteonecrosis (ON) in the knee occurs as a localized inflammatory disease in relation to spontaneous or non-traumatic ON. Conservative treatment possibilities are limited, and prognosis appears to be poor; in most cases, ON results in knee arthroplasty. Bisphosphonates are suggested to prevent bone resorption and collapse of necrotic bone. In this observational, prospective study we investigated the effect of bisphosphonate treatment in patients with spontaneous or arthroscopy-induced ON of the knee. Twenty-eight patients with osteonecrotic lesions and bone marrow oedema in the knee were included. In 22 patients (80%), ON was identified after arthroscopic surgery of the knee; six patients were diagnosed with spontaneous ON. Patients were initially given pamidronate 120 mg i.v. divided in 3-4 perfusions over 2 weeks, followed by oral bisphosphonate treatment with alendronate 70 mg weekly for 4-6 months. Bisphosphonate treatment resulted in a rapid pain relief, VAS decreasing from 8.2 ± 1.2 at baseline to 5.02 ± 0.6 after 4-6 weeks (p < 0.001). After 6 months, the VAS decreased by 80% (p < 0.001). At the 6-month follow-up, symptoms had resolved completely in 15 patients out of 28; in 6 patients, minimal symptoms (VAS 1-2) remained. In two patients, treatment effect was unsatisfactory, and surgical intervention was needed (arthroplasty). Bone marrow oedema on MRI resolved completely in 18 patients out of 28 with substantial reduction in the remaining. Furthermore, osteonecrotic area resolved completely or demarcation with sclerotic changes of the necrotic area could be observed. Bisphosphonate treatment in patients with osteonecrosis of the knee was associated with a rapid improvement in pain score and radiological consolidation of the area of osteonecrosis. Further randomized, controlled trials are warranted to confirm the potential beneficial role of bisphosphonates in the treatment of osteonecrosis of the knee.

LEVEL OF EVIDENCE

observational study, level IV.

Rationale for prostaglandin I2 in bone marrow oedema--from theory to application

Introduction

Bone marrow oedema (BME) and avascular osteonecrosis (AVN) are disorders of unclear origin. Although there are numerous operative and non-operative treatments for AVN, pain management in patients with AVN remains challenging. Prostaglandins play an important role in inflammatory responses and cell differentiation. It is thought that prostaglandin I₂ ([PGI₂] or synonoma prostacyclin) and its analogues promote bone regeneration on a cellular or systemic level. The purpose of this study was to assess the curative and symptomatic efficacy of the prostacyclin analogue iloprost in BME and AVN patients.

Method

We are reporting on 50 patients (117 bones) affected by BME/AVN who were treated with iloprost. Pain levels before, during and 3 and 6 months after iloprost application were evaluated by a visual analogue scale (VAS). The short form(SF)-36 health survey served to judge general health status before and after treatment. Harris Hip Score (HHS) and Knee Society Score (KSS) were performed as functional scores and MRI and X-rays before and 3 and 6 months after iloprost application served as objective parameters for morphological changes of the affected bones.

Results

We found a significant improvement in pain, functional and radiological outcome in BME and early AVN stages after iloprost application, whereas patients with advanced AVN stages did not benefit from iloprost infusions. Mean pain level decreased from 5.26 (day 0) to 1.63 (6 months) and both HHS and KSS increased during follow-up. Moreover, the SF-36 increased from 353.2 (day 0) to 560.5 points (6 months). We found a significant decrease in BME on MRI scans after iloprost application.

Conclusions

In addition to other drugs, iloprost may be an alternative substance which should be considered in the treatment of BME/AVN-associated pain.

Natural course of intra-articular shifting bone marrow edema syndrome of the knee

Background

Intra-articular shift (migration) of bone marrow edema syndrome (BMES) is a very rare disease. Only a few cases have been reported thus far. The condition may cause the clinician to suspect an aggressive disease.

Methods

We reviewed eight patients (four women and four men) with unilateral BMES located in the knee. The patients were aged 39 to 56 years (mean, 49.2 years). In all patients, bone marrow edema (BME) initially observed on magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or the adjacent bone. Seven patients were given conservative therapy, including limited weight-bearing, for a period of three weeks after the initial detection of BMES, whereas one patient underwent surgical core decompression twice.

Results

MR imaging showed complete restitution in 6 cases and a small residual edema in one case. A final control MR could not be obtained for one patient, who had no pain. A further patient had an avascular necrosis of the contralateral hip after 16 months. Improvement on MR imaging was correlated with the clinical outcome in all cases. All patients became asymptomatic after a mean period of 9 months (6–11).

Interpretation

Intra-articular shifting BMES is a very rare condition. As the disease is self-limiting, conservative therapy may be recommended.

Osteochondral Lesions of the Talus

Osteochondral lesions of the talus can present as a late complication of ankle injuries. As the talus is largely covered by articular cartilage, it has a limited ability for repair. Early and accurate diagnosis is important as talar integrity is required for optimal function of the ankle. The common presentation is chronic ankle pain with a history of ankle trauma. Conservative treatment involving a period of casting and non-weight-bearing is recommended for acute, non-displaced osteochondral lesions. Surgical management is recommended for unstable lesions or failed conservative management. Key words: Ankle sprains, Arthroscopy, Cartilage culture, Osteochondral graft

Spontaneous osteonecrosis of the knee: biochemical markers of bone turnover and pathohistology

OBJECTIVE

The aim of this study was to evaluate bone metabolism in patients with spontaneous osteonecrosis (ON) of the medial femoral condyle.

METHOD

In 22 consecutive patients, undergoing total knee arthroplasty, biochemical markers of bone metabolism were measured in aspirates from cancellous bone and in samples obtained simultaneously from peripheral blood. Specimens of the medial femoral condyle were available for histologic examination and the lesion size, assessed on radiographs, was compared with the results from bone turnover measurements. Twenty patients with osteoarthritis (OA) of the knee served as a control. Bone-specific alkaline phosphatase (bone ALP), osteocalcin (OC), procollagen type I N-terminal propeptide (PINP), and C-terminal cross-linking telopeptide (ICTP) were studied.

RESULTS

Mean serum levels of analytes were not different in patients with ON and OA. The serum concentrations averaged 16.2 vs 13.3 ng/mL (OC), 10.2 vs 12.1 ng/mL (bone ALP), 4.6 vs 4.1 ng/mL (ICTP), and 33.2 vs 40.4 ng/mL (PINP) in patients with ON and OA, respectively. In samples obtained from cancellous bone, mean concentrations of all markers were elevated significantly when compared to serum levels. The mean marker concentrations in samples obtained from cancellous bone were 33.8 vs 43.3 ng/mL (OC), 34.6 vs 37.3 ng/mL (bone ALP), 64.8 vs 36.1 ng/mL (ICTP, P=0.02), and 208.0 vs 176.2 ng/mL (PINP) in patients with ON and OA, respectively. The lesion size was at mean 440.5+/-275.8mm(2) in knees with ON and did not correlate with either serum or bone concentrations of all markers tested (P>0.1).

CONCLUSION

The marked elevation of markers in samples obtained from cancellous bone pointed at increased turnover in both diseases when compared to healthy individuals. In line with histologic findings of necrosis of subchondral bone, focal degradation of collagen type I was more pronounced in knees with ON. Mean serum concentrations of all markers, however, were not different from healthy individuals and thus did not provide any useful clue in the diagnosis spontaneous ON.