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Buturoiu MM, Ghiea S, Weber MA. Subchondral insufficiency fractures: overview of MRI findings from hip to ankle joint. ROFO-FORTSCHR RONTG 2024. [PMID: 39029510 DOI: 10.1055/a-2344-5337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
Subchondral insufficiency fracture (SIF) represents a potentially severe condition that can advance to osteoarthritis, with collapse of the articular surface. SIF manifests as a fracture in bone weakened by non-tumorous disease, precipitated by repetitive physiological stress, without a clear history of major trauma. It is observed along the central weight-bearing region of the femoral condyle, with a higher incidence in the medial femoral condyle, but also in other large weight-bearing synovial joints, such as the femoral head, tibial plateau, or talus.A review of the literature from the past six years was performed by searching PubMed and ScienceDirect databases, using the keywords "subchondral insufficiency fracture" and "spontaneous osteonecrosis of the knee". The inclusion criteria were scientific papers presented in the English language that reported on the magnetic resonance imaging (MRI) aspects of SIF of the lower limb.Detecting SIF at the level of the hip, knee, and ankle may present challenges both clinically and radiologically. The MRI appearance is dominated by a bone marrow edema-like signal and subchondral bone changes that can sometimes be subtle. Subchondral abnormalities are more specific than the pattern of bone marrow edema-like signal and are best shown on T2-weighted and proton-density-weighted MR images. MRI plays an important role in accurately depicting even subtle subchondral fractures at the onset of the disease and proves valuable in follow-up, prognosis, and the differentiation of SIF from other conditions. · Subchondral insufficiency fractures may affect the hip, knee, and ankle.. · Subchondral insufficiency fractures may heal spontaneously or progress to collapse.. · MRI is important for the detection, follow-up, and prognosis of subchondral insufficiency fractures.. · Differential diagnosis may include transient osteoporosis and osteonecrosis of systemic origin.. · Buturoiu MM, Ghiea S, Weber M. Subchondral insufficiency fractures: overview of MRI findings from hip to ankle joint. Fortschr Röntgenstr 2024; DOI 10.1055/a-2344-5337.
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Affiliation(s)
- Monica Maria Buturoiu
- Radiology, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Sorin Ghiea
- Imaging Department, Monza Hospital, Bucharest, Romania
| | - Marc-André Weber
- Rostock University Medical Center, Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock, Germany
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2
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Alidina S, Luxenburg D, Castro A, Subhawong TK, Ferreira de Souza F. Imaging Review of Different Subchondral Insufficiency Fractures. J Comput Assist Tomogr 2024; 48:663-668. [PMID: 38834938 DOI: 10.1097/rct.0000000000001628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
ABSTRACT Subchondral fractures are a common cause of joint pain that may ultimately lead to articular collapse and the need for arthroplasty. This type of fracture has been reported at multiple joints throughout the body. While clinical and radiographic resolution can be achieved, progressive bone collapse can occur and lead to a variety of complications. Understanding the pertinent imaging findings can aid in the early evaluation of subchondral fractures and in the prevention of their associated complications.
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Affiliation(s)
- Sameer Alidina
- From the Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
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3
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Kweon SH, Park JS, Baek SJ. Outcomes of Hybrid Total Hip Arthroplasty for Subchondral Insufficiency Fracture of the Femoral Head. Clin Orthop Surg 2024; 16:390-396. [PMID: 38827754 PMCID: PMC11130634 DOI: 10.4055/cios23189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 06/04/2024] Open
Abstract
Background The purpose of this study was to evaluate functional outcomes, radiologic results, and complications after hybrid total hip arthroplasty (THA) in patients with subchondral insufficiency fractures (SIFs) of the femoral head. Methods From June 2009 to December 2020, among 985 patients who underwent hybrid THA at our hospital, 19 patients diagnosed with SIF through a retrospective chart review were included. Those under 50 years of age, with radiographic findings of osteonecrosis on the contralateral side of surgery, a history of organ transplantation, and alcohol abuse, were excluded. Functional evaluation was performed using a modified Harris Hip Score (HHS). After surgery, inclination and anteversion of the acetabular cup and version of the femoral system were measured using postoperative x-ray. The outpatient follow-up was performed at 6 weeks, 3 months, 9 months, and 12 months after surgery and every year thereafter. Complications including dislocation, implant loosening, stem subsidence, and periprosthetic infection were observed on follow-up radiographs. Results The average follow-up time was 29.3 ± 9.1 months (range, 24-64 months) with no loss to follow-up. The mean modified HHS was 83.4 ± 9.6 (range, 65-100) at the last outpatient clinic follow-up. The average inclination of the acetabular cup was 41.9° ± 3.4° (range, 37°-48°), and the anteversion was 27.5° ± 6.7° (range, 18°-39°). The version of the femoral stem was 19° ± 5.7° (range, 12°-29°). There was no case of intraoperative fracture. There were no cases of dislocation, loosening of the cup, subsidence of the femoral stem, intraoperative or periprosthetic fracture, or periprosthetic infection on the follow-up radiographs. Conclusions In our study, hybrid THA showed favorable outcomes in patients diagnosed with SIF, and there were no further special considerations as for THA performed due to other diseases or fractures.
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Affiliation(s)
- Suc-Hyun Kweon
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Jin Sung Park
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Seung Jeong Baek
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
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4
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Watanabe N, Ogawa T, Miyatake K, Takada R, Jinno T, Koga H, Yoshii T. Increased bone resorption that outpaces increased bone formation: An important pathology of rapidly destructive coxarthrosis. J Orthop Res 2024; 42:1066-1073. [PMID: 38044471 DOI: 10.1002/jor.25760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
Rapid joint destruction caused by rapidly destructive coxarthrosis (RDC) can increase surgical complexity and intraoperative blood loss. This single-center retrospective study investigates osteoporosis-related biomarkers for early RDC diagnosis and explores new treatment targets. We included 398 hip joints from patients who underwent total hip arthroplasty, examining medical records for preoperative patient demographics, bone mineral density of the hip and lumbar spine from dual-energy X-ray absorptiometry scans, and osteoporosis-related biomarkers including TRACP-5b, total P1NP, intact parathyroid hormone, and homocysteine. We compared RDC and osteoarthritis (OA) patients, and univariate analysis showed that RDC patients were older (p < 0.001) and had lower serum levels of albumin (p < 0.001) and higher serum levels of TRACP-5b, total P1NP (p < 0.001), and homocysteine (p = 0.006). Multivariable analysis showed that the ratio of serum TRACP-5b to total P1NP had a more significant difference in RDC patients than in OA patients (p = 0.04). Serum TRACP-5b levels were negatively correlated with the time between RDC onset and blood collection, and Japanese Orthopedic Association pain score. Receiver operating characteristic curve analysis revealed that the ratio of serum TRACP-5b to total P1NP had the highest area under the curve value. This study is the first to demonstrate that the ratio of serum TRACP-5b to total P1NP-increased bone resorption that outpaces increased bone formation-is significantly elevated in patients with RDC and that TRACP-5b is higher in the early stages of RDC. Inhibiting serum levels of TRACP-5b, activated osteoclasts, during early RDC may suppress disease progression.
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Affiliation(s)
- Naoto Watanabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahisa Ogawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryohei Takada
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Jinno
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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5
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Otaka K, Osawa Y, Takegami Y, Seki T, Imagama S. Intertrochanteric curved varus osteotomy for subchondral fracture of the femoral head: a case series. ARTHROPLASTY 2023; 5:46. [PMID: 37667396 PMCID: PMC10478382 DOI: 10.1186/s42836-023-00202-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 09/06/2023] Open
Abstract
Although favorable results have been reported with total hip arthroplasty, joint-preserving treatment should be the first choice for subchondral fracture of the femoral head (SFF) in young patients. This study reviewed four young male patients with SFF who underwent intertrochanteric curved varus osteotomy (CVO). The patients had a mean age of 32.3 years (range: 18-49 years). Conservative treatment was initially attempted in all cases, but failed to alleviate the pain, leading to surgical intervention at an average time of 6 months (range: 4-10 months) after symptom onset. As the fracture sites were located medial to the lateral edge of the acetabulum in all cases, CVO was performed to achieve a postoperative intact ratio of ≥ 34% in the weight-bearing region of the femoral head. The average follow-up period after surgery lasted 4.3 years (range: 2-7 years). Clinical and radiographic assessments were performed pre- and postoperatively. At the latest follow-up, the mean Harris hip score improved from 67.3 preoperatively to 99.5 postoperatively. The average preoperative intact ratio of the weight-bearing region of the femoral head was 12.3%, which increased to 44.3% postoperatively. No progression to femoral head collapse or joint space narrowing was observed on the plain radiographs. CVO is a simple, less-invasive, and beneficial approach for treating SFF in young patients whose fractures occur medial to the lateral edge of the acetabulum.
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Affiliation(s)
- Keiji Otaka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
- Department of Orthopaedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, 453-8511, Japan
| | - Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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6
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Yoon HK, Choi MH, Lee H, Park J, Ahn J. Subchondral stress fracture of the femoral head (SSFFH) in young and healthy military recruits: clinical recommendations and fracture configurations on MRI. INTERNATIONAL ORTHOPAEDICS 2023; 47:1315-1321. [PMID: 36829086 DOI: 10.1007/s00264-023-05739-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/16/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE This study aimed to evaluate the clinical and radiologic characteristics of the fatigue-type of SSFFH in healthy military recruits. MATERIALS AND METHOD We retrospectively analyzed 39 hips from 32 patients who were treated for SSFFH between 2014 and 2018. Clinical variables were analyzed. We devised a categorization system that divided SSFFH into five types (A-E) according to the extent of the fracture line MRI axial view. The femoral head was divided into three parts for the categorization: the anterior third, middle third, and posterior third. RESULTS The included patients were 39 hips from 32 patients with the mean age 22.3 years. Almost all patients with SSFFH (96.9%) complained of hip pain with limping at the time of diagnosis. The mean time to the onset of the hip pain from the beginning of military training was 24.8 days. There were seven patients (21.9%) with concomitant stress fractures on whole-body bone scan. Six hips (15.4%) developed osteoarthritis and required surgery. Almost all the cases (94.9%) involved the anterior compartment of the femoral head. CONCLUSIONS Military recruits with the hip pain and limping within one month of military training should undergo detailed evaluation. A whole-body bone scan with SPECT is useful for identifying other concomitant stress fractures. Majority of SSFFH involved the anterior compartment of the femoral head.
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Affiliation(s)
- Hyung Ku Yoon
- Department of Orthopaedic Surgery, Armed Forces Capital Hospital, 81, Saemaeul-Ro 177Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Min-Ho Choi
- Department of Orthopaedic Surgery, Armed Forces Capital Hospital, 81, Saemaeul-Ro 177Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Ho Lee
- Department of Orthopaedic Surgery, Armed Forces Capital Hospital, 81, Saemaeul-Ro 177Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Jinyong Park
- Department of Orthopaedic Surgery, Armed Forces Capital Hospital, 81, Saemaeul-Ro 177Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Joosuk Ahn
- Department of Orthopaedic Surgery, Armed Forces Capital Hospital, 81, Saemaeul-Ro 177Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Republic of Korea.
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Chen M, Wang X, Takahashi E, Kaneuji A, Zhou Y, Kawahara N. Current Research on Subchondral Insufficiency Fracture of the Femoral Head. Clin Orthop Surg 2022; 14:477-485. [PMID: 36518923 PMCID: PMC9715932 DOI: 10.4055/cios22175] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 09/06/2023] Open
Abstract
Subchondral insufficiency fracture (SIF) of the femoral head is one of the predominant etiologies of rapidly progressive osteoarthritis of the hip (RPOH). SIF is a rare disease that causes acute pain in the hip joint. It is most frequently found in elderly women with osteoporosis. It is often underdiagnosed or misdiagnosed as osteonecrosis of the femoral head. SIF is currently a well-established cause of RPOH; however, the deeper etiology of SIF is not clear. Good clinical outcomes have been reported for hip preservation therapy and hip replacement. SIF is not obvious radiologically in the early stage, and a T1-weighted magnetic resonance imaging shows a discontinuous low-intensity band under the articular cartilage convex to the articular surface as its characteristic manifestation. Some patients will lose the opportunity to preserve the hip joint due to symptoms such as progressive joint space narrowing and subchondral collapse within a very short period. Patients with progressive hip space narrowing and subchondral collapse on X-ray should be converted to total hip arthroplasty. Based on the characteristics of the disease, surgeons need to master the clinical and radiological characteristics of SIF and strive for early diagnosis and treatment.
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Affiliation(s)
- Mingliang Chen
- Department of Orthopedic Surgery, Kanazawa Medical University, Uchinada-machi, Japan
- Department of Orthopedics, Affiliated Renhe Hospital of China Three Gorges University, Yichang, China
| | - Xipeng Wang
- Department of Orthopaedic Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Eiji Takahashi
- Department of Orthopedic Surgery, Kanazawa Medical University, Uchinada-machi, Japan
| | - Ayumi Kaneuji
- Department of Orthopedic Surgery, Kanazawa Medical University, Uchinada-machi, Japan
| | - You Zhou
- Department of Orthopedics, Affiliated Renhe Hospital of China Three Gorges University, Yichang, China
| | - Norio Kawahara
- Department of Orthopedic Surgery, Kanazawa Medical University, Uchinada-machi, Japan
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8
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The influence of bone marrow edema for the assessment of the boundaries of necrotic lesions in patients with osteonecrosis of the femoral head. Sci Rep 2022; 12:18649. [PMID: 36333527 PMCID: PMC9636171 DOI: 10.1038/s41598-022-23427-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
This study aimed to investigate the influence of bone marrow edema (BME) for the assessment of the boundaries of necrotic lesions using unenhanced and contrast-enhanced (CE) magnetic resonance (MR) images in patients with osteonecrosis of the femoral head (ONFH). We retrospectively reviewed 72 consecutive hips in 55 patients of ONFH that were Association Research Circulation Osseous (ARCO) stage III or higher and underwent both unenhanced and contrast-enhanced MR imaging between January 2005 and February 2016. The degree of extension of BMEs, and the boundaries of the necrotic lesions were compared using unenhanced and CE MR images on both mid coronal and mid oblique-axial slices. Forty-two percent of the coronal T1 images, 40% of the coronal fat-saturated T2 images, and 48% of the oblique-axial T1 images showed differences in the boundaries of necrotic lesion, by comparison with those of CET1-weighted MR images. The boundaries of necrotic lesions were clearly detected in all hips on CE coronal slices and 97% of all hips on CE oblique-axial slices. The BME grade in the difference group was significantly higher than in the non-difference group on the coronal plane (P = 0.0058). There were significant differences between the BME grade and duration from the onset of hip pain to MR imaging examination. Multivariate analyses revealed that the duration from the onset to MR imaging examination in both coronal (P = 0.0008) and oblique-axial slices (P = 0.0143) were independently associated with differences in the boundary of necrotic lesion between T1 and CET1-weighted MR images. Our findings suggest that unenhanced MR image may be insufficient for a precise assessment of the boundaries of the necrotic lesions for ONFH cases in the early phase of subchondral collapse due to the diffuse BME.
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Mandell JC, Khurana B. Musculoskeletal Trauma and Infection. Magn Reson Imaging Clin N Am 2022; 30:441-454. [PMID: 35995472 DOI: 10.1016/j.mric.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
MR is often the most definitive imaging for assessment of musculoskeletal trauma and infection. Although it is not possible to address all the intricacies of these complex topics in a single article, this review will attempt to provide a useful toolbox of skills by discussing several common clinical scenarios faced by emergency radiologists in interpretation of adult trauma and infection. These scenarios include MR assessment of hip and pelvic fracture, traumatic soft tissue injuries, septic arthritis, soft tissue infection, and osteomyelitis.
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Affiliation(s)
- Jacob C Mandell
- Musculoskeletal Imaging and Intervention, Division of Musculoskeletal Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Bharti Khurana
- Division of Emergency Radiology, Brigham and Women's Hospital, Trauma Imaging Research and Innovation Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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10
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Lee YK, Won SH, Park JW, Im JW, Ha YC, Koo KH. Cementless Hip Arthroplasty in Patients with Subchondral Insufficiency Fracture of the Femoral Head. J Bone Joint Surg Am 2022; 104:84-89. [PMID: 34788256 DOI: 10.2106/jbjs.20.00410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Subchondral insufficiency fracture of the femoral head (SIFFH) occurs in elderly patients and might be confused with osteonecrosis of the femoral head (ONFH). Subchondral insufficiency fracture of the femoral head is an insufficiency fracture at the dome of the femoral head and has been known to be associated with osteoporosis, hip dysplasia, and posterior pelvic tilt. This study's aims were to evaluate (1) surgical complications, (2) radiological changes, (3) clinical results, and (4) survivorship of THA in patients with SIFFH. METHODS From November 2010 to June 2017, 21 patients (23 hips); 5 men (5 hips) and 16 women (18 hips) underwent cementless THA due to SIFFH at our institution. Their mean age was 71.9 years (range, 57 to 86) at the time of surgery, and mean T-score was -2.2 (range, -4.2 to 0.2). The mean lateral center-edge angle, abduction, and anteversion of the acetabulum were 29.9° (range, 14.8° to 47.5°), 38.5° (range, 31° to 45°), and 20.0° (range, 12° to 25°), respectively. The mean pelvic incidence, lumbar kyphotic angle and posterior pelvic tilt were 56.4° (range, 39° to 79°), 14.7° (range, -34° to 43°), and 13.0° (range, 3° to 34°), respectively. RESULTS An intraoperative calcar crack occurred in 1 hip. The mean anteversion and abduction of cup were 29.0° (range, 17° to 43°) and 43.3° (range, 37° to 50°), respectively. One patient sustained a traumatic posterior hip dislocation 2 weeks after the procedure, and was treated with open reduction. At a mean follow-up of 35.4 months (range, 24 to 79 months), no hip had prosthetic loosening or focal osteolysis. At the latest follow-up, the mean modified Harris hip score was 79.1 (range, 60 to 100) points, and mean UCLA activity score was 4.2 (range, 2 to 7) points. The survivorship was 95.7% (95% CI, 94.9% to 100%) at 6 years. CONCLUSIONS Cementless THA is a favorable treatment option for SIFFH in elderly patients. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Seok-Hyung Won
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Woo Im
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Seoul, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
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11
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Tarantino U, Greggi C, Cariati I, Caldora P, Capanna R, Capone A, Civinini R, Colagrande S, De Biase P, Falez F, Iolascon G, Maraghelli D, Masi L, Cerinic MM, Sessa G, Brandi ML. Bone Marrow Edema: Overview of Etiology and Treatment Strategies. J Bone Joint Surg Am 2022; 104:189-200. [PMID: 34780382 DOI: 10.2106/jbjs.21.00300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Bone marrow edema (BME) is a nonspecific but relevant finding, usually indicating the presence of an underlying pathology. ➤ The gold standard technique for detecting BME is magnetic resonance imaging (MRI), as it allows for a correct diagnosis to be made, which is extremely important given the heterogeneity of BME-related diseases. ➤ Depending on the severity of painful symptomatology and the MRI evidence, different treatment strategies can be followed: physical modalities, pharmacological options, and surgical therapy.
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Affiliation(s)
- Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy.,Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - Chiara Greggi
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy.,Medical-Surgical Biotechnologies and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy
| | - Ida Cariati
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy.,Medical-Surgical Biotechnologies and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy
| | | | - Rodolfo Capanna
- Department of Orthopaedics and Traumatology, Universal Hospital of Pisa, Pisa, Italy
| | - Antonio Capone
- Department of Surgical Sciences, University of Cagliari, Monserrato, Italy
| | - Roberto Civinini
- Department of Surgical Science, University of Florence, Florence, Italy
| | - Stefano Colagrande
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Pietro De Biase
- General Orthopaedics and Traumatology, AOU Careggi, Florence, Italy
| | - Francesco Falez
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli," Caserta, Italy
| | - Davide Maraghelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Laura Masi
- Metabolic Bone Diseases Unit, University Hospital of Florence, AOU Careggi, Florence, Italy
| | - Marco Matucci Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe Sessa
- Section of Orthopaedics and Traumatology, Department of General Surgery and Medical Surgical Specialties, University Hospital Policlinico Rodolico-San Marco, University of Catania, Catania, Italy
| | - Maria L Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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12
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Chen Y, Miao Y, Liu K, Xue F, Zhu B, Zhang C, Li G. Evolutionary course of the femoral head osteonecrosis: Histopathological - radiologic characteristics and clinical staging systems. J Orthop Translat 2022; 32:28-40. [PMID: 35591937 PMCID: PMC9072800 DOI: 10.1016/j.jot.2021.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023] Open
Abstract
Osteonecrosis of the femoral head (ONFH) is a recalcitrant ischemic disorder, which could be classified into two major categories: traumatic and nontraumatic. Regardless of different risk factors, it has been testified that ONFH results from primitive vascular problems, leading to temporary or permanent loss of blood supply to bone tissue. Histopathological and microarchitectural alterations ensues, which is a gradual evolutionary process involving bone marrow and osteocyte necrosis, progressive destruction of subchondral bone, unsuccessful reparative process, and eventual articular collapse and degenerative arthritis. Based on the imaging features of ONFH, different classification systems have been developed to evaluate the severity and prognosis of the disease, which is pivotal for implementation of treatment strategy, especially the joint-preserving surgery. However, patients classified with the same severity stage, especially in the peri-collapse stage, sometimes responded differently after similar joint-preserving surgery. The unusual phenomenon may be attributed to the limitation of the current imaging classification systems, which might underestimate the disease severity, especially when referring to the early stages. In this review, we briefly summarize the etiology and pathogenesis of ONFH. The imaging features and staging classification systems of ONFH are also described. More importantly, we focus on histopathological and microstructural alterations of the femoral head, and provide an overview of their essential contribution to ONFH progression. Given the observation of discordance between imaging characteristics and histopathological alterations, a substantial amount of research on the relationship between imaging and histopathological features is required to further modify and revise the current wide-accepted classification systems.
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Zheng Y, Zheng Z, Zhang K, Zhu P. Osteonecrosis in systemic lupus erythematosus: Systematic insight from the epidemiology, pathogenesis, diagnosis and management. Autoimmun Rev 2021; 21:102992. [PMID: 34793961 DOI: 10.1016/j.autrev.2021.102992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/14/2021] [Indexed: 02/08/2023]
Abstract
Osteonecrosis (ON) is one of the serious and well recognized complicationscausing severe pain and disability in patients with systemic lupus erythematosus (SLE), and its manifestation and pathogenesis are only partially understood. This review provide an update of the recent progress in etiology, pathogenesis, diagnosis, and treatment of systemic lupus erythematosus related osteonecrosis (SLE-ON). Despite the concomitant use of corticosteroids, alcohol and obesity, the dysregulated immune micro-environment and the complex pathogenesis of SLE synergistically play important roles in the development of ON. Osteonecrosis of femoral head (ONFH) is the most often involved joint in SLE. The current classification and staging system of ONFH is based on imaging techniques, particularly relating to MRI and CT, for the identification and quantification of necrotic lesions. For SLE-ONFH patients, both SLE specific clinical symptoms and ONFH imaging findings should be comprehensively evaluated. Even though advances concerning bone grafting and arthroplasty procedures have resulted in improved clinical outcomes, early pharmacological treatment at the pre-collapse stage may prevent joint collapse and reduce the joint arthroplasty rate, and this needs to be accounted. Although some progress has been made, considerably more research is needed before we fully understand SLE-ONFH. Future treatments of SLE-ONFH may involve genetic or cell-based therapies that target potential biomarkers, and this will lead to effective measures for saving thefunction of hip joint and preventing osteonecrosis.
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Affiliation(s)
- Yan Zheng
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Shaanxi Province, PR China; National Translational Science Center for Molecular Medicine, Xi'an, Shaanxi Province, PR China
| | - Zhaohui Zheng
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Shaanxi Province, PR China
| | - Kui Zhang
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Shaanxi Province, PR China
| | - Ping Zhu
- Department of Clinical Immunology, Xijing Hospital, The Fourth Military Medical University, Shaanxi Province, PR China; National Translational Science Center for Molecular Medicine, Xi'an, Shaanxi Province, PR China.
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14
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Ran TF, Ke S, Li J, Lyu MR, Zhou YY, Zhang R, Song X, Wang M. Relieved Low Back Pain after Total Hip Arthroplasty in Patients with Both Hip Osteoarthritis and Lumbar Degenerative Disease. Orthop Surg 2021; 13:1882-1889. [PMID: 34605608 PMCID: PMC8523762 DOI: 10.1111/os.13135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/25/2021] [Accepted: 06/22/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the relief of low back pain after hip arthroplasty in patients with hip joint and spinal degenerative diseases, and to discuss the effects of unilateral and bilateral hip surgery on the relief of low back pain. Methods In this retrospective study, we followed 153 patients (69 males and 84 females, age: 43–88 years) who had undergone total hip arthroplasty (THA) via a posterolateral approach and also suffered from lumbar degenerative diseases in the period of 2009 to 2019. The inclusion criteria were: (i) patients who had been diagnosed with severe hip degenerative disease and also been diagnosed with lumbar degenerative disease; (ii) patients who had undergone THA surgery; and (iii) patients who were retrospectively recruited. The exclusion criteria were: (i) patients who had undergone lumbar fusion or internal fixation surgery; or (ii) patients who had vascular claudication, history of major trauma, diabetic polyneuropathy, lumbar and pelvic infections, tumor diseases; (iii) or patients who had undergone THA because of femoral neck fracture or ankylosing spondylitis. The improvement of hip joint function and the relief of low back pain (LBP) were studied, and the effect of unilateral and bilateral THA on the relief of LBP were discussed. Hip pain and function were evaluated by the Harris Hip Score (HHS), LBP was evaluated by Visual Analog Scale (VAS), and lumbar function was evaluated by the Japanese Orthopaedic Association (JOA) scoring system. Results The average follow‐up time was 44.3 months (24–108 months). All patients recovered smoothly without complications. The LBP VAS of 153 patients decreased from 4.13 ± 1.37 preoperatively to 1.90 ± 1.44 postoperatively. The average HHS increased from 45.33 ± 13.23 preoperatively to 86.44 ± 7.59 postoperatively at the latest follow‐up. According to Japanese Orthopaedic Association scoring system, the proportion of patients with good response to treatment in these 153 patients reached 93.46%. LBP VAS decreased from 4.18 ± 1.38 preoperatively to 1.95 ± 1.49 postoperatively in unilateral group and from 3.94 ± 1.32 preoperatively to 1.73 ± 1.23 postoperatively in bilateral group, respectively. There were only nine patients with persistent or aggravated LBP after operation. Among them, six patients underwent subsequent lumbar surgery (five patients had pain relieved after reoperation and one patient had not) and the other three patients chose conservative treatment for pain. Conclusion THA can relieve LBP while relieving hip pain and restoring hip function in patients with both hip and lumbar degenerative disease, thus possibly avoiding further spinal surgery.
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Affiliation(s)
- Tian-Fei Ran
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
| | - Song Ke
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
| | - Jie Li
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
| | - Ming-Rui Lyu
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
| | - Yuan-Yuan Zhou
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
| | - Rui Zhang
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Xin Song
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
| | - Min Wang
- Department of Orthopaedics, Xinqiao Hospital, Amy Medical University (Third Military Medical University), Chongqing, China
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15
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Abstract
Atraumatic fractures of femur, although not as common as traumatic fractures, are frequently encountered in the clinical practice. They present with non-specific symptoms and can be occult on initial imaging making their diagnosis difficult, sometimes resulting in complications. Overlapping terminologies used to describe these fractures may hamper effective communication between the radiologist and the clinician. In this article, we review various atraumatic fractures of femur, terminologies used to describe them, their imaging findings and differential diagnosis. The article also describes the aetiology, pathophysiology and relevant biomechanics behind these fractures. An approach to atraumatic femoral fractures has been outlined.
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Affiliation(s)
- Ganesh Hedge
- Department of Radiology, Royal Lancaster Infirmary, Lancaster, UK
| | - Siddharth Thaker
- Department of Musculoskeletal Radiology, Leeds Teaching Hospitals, Leeds, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
| | - Richard Fawcett
- Department of Musculoskeletal Radiology, Leeds Teaching Hospitals, Leeds, UK
| | - Harun Gupta
- Department of Musculoskeletal Radiology, Leeds Teaching Hospitals, Leeds, UK
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16
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Geith T, Stellwag AC, E Müller P, Reiser M, Baur-Melnyk A. Is bone marrow edema syndrome a precursor of hip or knee osteonecrosis? Results of 49 patients and review of the literature. ACTA ACUST UNITED AC 2021; 26:355-362. [PMID: 32558648 DOI: 10.5152/dir.2020.19188] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Diagnosis of bone marrow edema syndrome (BMES) can be challenging. There is sometimes uncertainty about the correct diagnosis of BMES on morphologic magnetic resonance imaging (MRI), since subchondral findings like lines and spots can be misinterpreted as "beginning" or "possible" avascular osteonecrosis (AVN). The aim of our study was to systematically assess the temporal course of BMES from first diagnosis on MRI until the end of clinical symptoms and the full disappearance of bone marrow edema (BME) to determine whether subchondral lines and spots detected in these patients can develop into osteonecrosis. METHODS In a combined retrospective and prospective study, we retrieved serial MRI scans of hips and knees with BME from the hospital database. According to clinical and imaging data, all patients with degenerative, infectious/inflammatory, rheumatic, neoplastic conditions and those showing typical osteonecrosis were excluded. We collected all available MRI examinations from first detection of BME until its disappearance. In case edema had not fully resolved in the last available MRI scan, we performed an MRI with an additional dynamic contrast-enhanced (DCE-MRI) sequence. For each MRI scan, we recorded the severity of edema, the presence of subchondral hypointense lines and the presence of subchondral focal hypointense zones on T1-weighted images by two independent readers. The DCE-MRI scans were used to calculate parameter maps to assess the perfusion characteristics. RESULTS The study comprised 49 patients aged 22-71 years. In total, 171 morphologic and 5 DCE-MRI scans were evaluated. In 44 patients (89.8%), the BMES completely healed without remnants. In 18 of 49 patients (36.7%), a subchondral line was present in the first MRI exam. Nine patients (18.4%) developed a subchondral line within 1-5 months after the first MRI. In total, 27 out of 49 patients (55.1%) had subchondral lines (12 knees, 15 hips) during the timeframe of the study. All subchondral lines disappeared in the timeframe of the study. Subchondral focal hypointense zones were present in 14 out of 49 patients (28.6%): in 9 cases, subchondral focal hypointense zones disappeared after a median of 5.5 months (range, 1-85 months), while in 5 cases, subchondral focal lesions persisted until the end of the study (up to more than 85 months) without edema in the surrounding bone. All persisting subchondral focal lesions were hyperperfused. These 5 patients had associated meniscal lesions. CONCLUSION Our study shows that subchondral lines and spots found in patients with BMES do not develop into AVN. Subchondral lines, which resemble subchondral insufficiency fractures, are associated with BMES. Subchondral focal T1-hypointense zones do not represent AVN; most probably these areas represent reparative processes within the subchondral bone, where tensile and shear force overload is present due to altered biomechanics.
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Affiliation(s)
- Tobias Geith
- Department of Interventional Radiology, Rechts der Isar Hospital, Technical University of Munich, Munich, Germany
| | - Ann-Cathrin Stellwag
- Department of Radiology, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Peter E Müller
- Department of Orthopedic Surgery, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Maximilian Reiser
- Department of Radiology, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andrea Baur-Melnyk
- Department of Radiology, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
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Yamaguchi R, Nakamura T, Yamamoto T, Takamura K, Yanagida H, Yamaguchi T, Nakashima Y. Subchondral fracture of the femoral head in children: Differential diagnosis of pediatric hip pain. J Orthop Surg (Hong Kong) 2021; 28:2309499020937862. [PMID: 32638645 DOI: 10.1177/2309499020937862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This report describes clinical and radiographic characteristics of two pediatric patients with a presumptive diagnosis of subchondral fracture of the femoral head made based on their clinical course and imaging findings. An 8-year-old boy and an 8-year-old girl had subchondral fracture in the femoral head without osteonecrosis, which was verified by contrast-enhanced magnetic resonance imaging. Although complete disappearance of the fracture line was confirmed in the boy, the girl had a residual femoral head deformity after conservative treatment. Subchondral fracture of the femoral head should be included in the differential diagnosis of pediatric hip pain.
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Affiliation(s)
- Ryosuke Yamaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoyuki Nakamura
- Department of Orthopaedic and Spine Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazuyuki Takamura
- Department of Orthopaedic and Spine Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Haruhisa Yanagida
- Department of Orthopaedic and Spine Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Toru Yamaguchi
- Department of Orthopaedic and Spine Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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18
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Comparison of Radiographic and Pathologic Diagnosis of Osteonecrosis of the Femoral Head. AJR Am J Roentgenol 2021; 216:1014-1021. [PMID: 33534621 DOI: 10.2214/ajr.20.22930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to assess the utility of radiography in diagnosing osteonecrosis of the femoral head with pathologic examination as the reference standard. MATERIALS AND METHODS. Radiography and pathology reports of 253 consecutive femoral head resections were reviewed. A subset of 128 cases in which the diagnosis of osteonecrosis was made or suggested radiographically or pathologically were reviewed to evaluate for factors that might influence correlation. A total of 23 patients in this subset had also undergone MRI, and those reports and images were reviewed. RESULTS. There was 93.9% agreement between radiography and pathologic examination overall (κ = 0.67). When grade 3 osteoarthritis was present, 95.0% agreement was found, but because of the large number of patients with severe osteoarthritis, the kappa value decreased to 0.51. In the subset of cases in which osteonecrosis was diagnosed or suspected, radiologic-pathologic correlation decreased as osteoarthritis grade increased, and the diagnostic uncertainty for both evaluation methods increased. One patient without osteoarthritis had osteonecrosis diagnosed in both hips at radiography and MRI, but osteonecrosis was absent at pathologic examination. CONCLUSION. Radiography depicts osteonecrosis in most patients who have osteonecrosis and subsequently undergo femoral head resection. False-positive and false-negative radiographic findings occur, however. Diagnosis is most difficult in patients with advanced osteoarthritis or subchondral fractures. The number of patients who underwent MRI was not sufficient for evaluation of the accuracy of MRI.
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19
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Ando W, Sakai T, Fukushima W, Kaneuji A, Ueshima K, Yamasaki T, Yamamoto T, Nishii T, Sugano N. Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head. J Orthop Sci 2021; 26:46-68. [PMID: 33388233 DOI: 10.1016/j.jos.2020.06.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE The Clinical Practice Guidelines for Osteonecrosis of the Femoral Head (ONFH) 2019 Edition, written by the working group for ONFH guidelines of the Japanese Investigation Committee (JIC) for ONFH under the auspices of the Japanese Ministry of Health, Labour, and Welfare and endorsed by the Japanese Orthopaedic Association, were published in Japanese in October 2019. The objective of this guideline is to provide a support tool for decision-making between doctors and patients. METHODS Procedures for developing this guideline were based on the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014, which proposed an appropriate method for preparing clinical guidelines in Japan. RESULTS This clinical practice guideline consists of 7 chapters: epidemiology; pathology; diagnosis; conservative therapy; surgical treatment: bone transplantation/cell therapy; surgical treatment: osteotomy; and surgical treatment: hip replacement. Twelve background questions and 13 clinical questions were determined to define the basic features of the disease and to be addressed when deciding treatment in daily practice, respectively. CONCLUSIONS The clinical practice guidelines for the ONFH 2019 edition will be useful for physicians, investigators, and medical staff in clinical practice, as well as for patients, during the decision-making process when defining how to treat ONFH.
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Affiliation(s)
- Wataru Ando
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Wakaba Fukushima
- Department of Public Health, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | - Ayumi Kaneuji
- Department of Orthopaedic Surgery, Kanazawa Medical University, Kahoku-gun, Ishikawa, Japan
| | - Keiichiro Ueshima
- Department of Orthopaedic Surgery, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Kyoto, Japan
| | - Takuma Yamasaki
- Department of Orthopaedic Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Fukuoka, Japan
| | - Takashi Nishii
- Department of Orthopaedic Surgery, Osaka General Medical Center, Osaka, Osaka, Japan
| | | | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
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20
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Ahmed AF, Hammad M, Salameh M, Ahmed GO. Destructive Osteonecrosis of the Femoral Head After a Single Intra-Articular Corticosteroid Injection: A Report of Two Cases. Int J Surg Case Rep 2020; 77:711-715. [PMID: 33395881 PMCID: PMC7718135 DOI: 10.1016/j.ijscr.2020.11.115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Accelerated femoral head avascular necrosis after a single dose intra-articular steroid injection is a rare pathology. Few cases were reported in the literature. Most cases were managed with total hip arthroplasty. CASE PRESENTATION In this study, we report two rare cases of destructive osteonecrosis of the femoral head. Both patients presented with hip osteoarthritis that failed nonoperative measures. A single intra-articular corticosteroid injection was administered for each patient. Both patients had femoral head destruction and significant resorption at 14 and 11 weeks, respectively. Septic arthritis was ruled out by blood tests and joint aspiration. Total hip arthroplasty (THA) was undertaken and histology reports confirmed the osteonecrosis. The postoperative follow-up was uneventful with satisfactory hip function. DISCUSSION AND CONCLUSION Destructive osteonecrosis of the femoral head is a rare catastrophic potential complication of intra-articular corticosteroid injection. Hence, physicians must consider this complication when counseling patients before an intra-articular corticosteroid hip injection.
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Affiliation(s)
- Abdulaziz F Ahmed
- Section of Orthopedics, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Mohammed Hammad
- Section of Orthopedics, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Motasem Salameh
- Section of Orthopedics, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Ghalib O Ahmed
- Section of Orthopedics, Department of Surgery, Hamad General Hospital, Doha, Qatar.
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21
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Magnetic resonance imaging of the hip: anatomy and pathology. Pol J Radiol 2020; 85:e489-e508. [PMID: 33101554 PMCID: PMC7571513 DOI: 10.5114/pjr.2020.99414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022] Open
Abstract
The aim of this review is to outline the normal anatomy of the hip and to discuss common painful conditions of the hip that affect the general adult population. Hip pain is a common complaint with many different etiologies. In this review, hip pathologies are divided by location into osseous, intra-articular and extra-articular lesions. Magnetic resonance imaging (MRI) is the modality of choice for investigating painful hip conditions due to its multiplanar capability and high contrast resolution. This review focuses on the characteristic MRI features of common traumatic and pathologic conditions of the hip.
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22
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Bone marrow edema around the hip in non-traumatic pain: dual-energy CT vs MRI. Eur Radiol 2020; 30:4098-4106. [DOI: 10.1007/s00330-020-06775-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/14/2020] [Accepted: 02/21/2020] [Indexed: 12/16/2022]
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23
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Suzuki A, Mine T, Ihara K, Kawamura H, Kuriyama R, Tominaga Y. Subchondral Insufficiency Fracture of the Femoral Head Complicated after Total Knee Arthroplasty. Open Orthop J 2019. [DOI: 10.2174/1874325001913010255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Subchondral Insufficiency Fracture (SIF) of the femoral head has been observed in elderly women with osteoporosis. We present a rare case of subchondral insufficiency fracture of the femoral head complicated after total knee arthroplasty. Histological findings suggested osteonecrosis or SIF of the femoral head. MRI characteristics were considered to be useful for the differentiation between osteonecrosis and SIF. Several pathological conditions may be related to SIF of the femoral head, but its detailed pathogenesis is still unknown.
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24
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Hatanaka H, Motomura G, Ikemura S, Kubo Y, Utsunomiya T, Baba S, Nakashima Y. Volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging is associated with disease severity after collapse in osteonecrosis of the femoral head. Skeletal Radiol 2019; 48:1193-1200. [PMID: 30697641 DOI: 10.1007/s00256-019-3158-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/06/2018] [Accepted: 01/10/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the relationship between the volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging (MRI) and the disease stage of osteonecrosis of the femoral head (ONFH). MATERIALS AND METHODS Sixty-three consecutive hips in 40 ONFH patients were reviewed using contrast-enhanced MRI. Ten unaffected hips in 10 patients with unilateral ONFH were used as controls. Based on the Japanese Investigation Committee system, these hips were classified according to stage and type. The volume and location of hip synovitis were semi-quantitatively measured on contrast-enhanced MRI. Clinicoradiological factors were statistically analyzed to determine the relationship with the volume of hip synovitis. RESULTS The mean synovial volume was significantly larger in ONFH hips (8,020 ± 6,900 mm3) than in controls (910 ± 1,320 mm3; p = 0.001). The area of synovitis in the anterior portion of the hip joint was double (mean: 2.17 ± 1.77) that in the posterior portion. The volume of synovitis was small in pre-collapse-stage hips (stage 1: 680 ± 690 mm3, stage 2: 1,460 ± 1,200 mm3), but significantly larger in post-collapse-stage hips (stage 3A: 7,820 ± 4,490 mm3, stage 3B: 13,850 ± 7,110 mm3; p < 0.001). Multiple regression analysis showed that disease stage was the only factor related to hip synovitis. CONCLUSIONS Our study suggests that hip synovitis in ONFH might occur after femoral head collapse and worsen with collapse progression, mainly in the anterior portion.
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Affiliation(s)
- Hiroyuki Hatanaka
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Goro Motomura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Satoshi Ikemura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yusuke Kubo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Utsunomiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shoji Baba
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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25
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Abstract
OBJECTIVE. The purpose of this article is to summarize the nomenclature of nonneoplastic conditions affecting subchondral bone through a review of the medical literature and expert opinion of the Society of Skeletal Radiology Subchondral Bone Nomenclature Committee. CONCLUSION. This consensus statement summarizes current understanding of the pathophysiologic characteristics and imaging findings of subchondral nonneoplastic bone lesions and proposes nomenclature to improve effective communication across clinical specialties and help avoid diagnostic errors that could affect patient care.
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26
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Magnetic resonance imaging of subchondral insufficiency fractures of the lower limb. Skeletal Radiol 2019; 48:1011-1021. [PMID: 30706108 DOI: 10.1007/s00256-019-3160-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/04/2018] [Accepted: 01/10/2019] [Indexed: 02/02/2023]
Abstract
Subchondral insufficiency fracture (SIF) is a non-traumatic condition that has historically been associated with elderly, osteoporotic women and patients with systemic conditions. There has been much work done to determine the pathogenesis of SIF, which has previously been regarded as idiopathic, rapid-progressive osteoarthritis or osteonecrosis of the hip, spontaneous osteonecrosis of the knee (SONK), osteochondral defect (OCD) of the talus and adult-onset Freiberg infraction of the metatarsal head. Early diagnosis and management are crucial to prevent subchondral collapse, secondary osteonecrosis and early-onset osteoarthritis. Magnetic resonance imaging (MRI) plays an important role in the diagnosis of SIF, which is often inconspicuous on initial radiographs. In this article, the authors provide an update on the role of MRI in identifying key imaging features of SIF in various joints of the lower limb to aid in its correct diagnosis.
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27
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Abstract
Subchondral osteonecrosis of large weight-bearing joints (hip and knee joints) represents a severe and joint-threatening disease. Apart from idiopathic forms, glucocorticoid medication and alcohol abuse have been identified as major causative factors for atraumatic osteonecrosis. In addition to direct cytotoxic factors, a critically reduced perfusion of the subchondral osseous space will eventually lead to bone marrow ischemia and osseous necrosis. Magnetic resonance imaging (MRI) is capable of visualizing a reactive border-like zone in this early, already irreversible and often asymptomatic stage I according to the Association of Research Circulation Osseous (ARCO) staging system. Later in the course, osteonecrosis progresses to form serpiginous sclerotic lines, enclosing the necrotic bone area (stage II ARCO). Repair mechanisms of osteonecrosis are mostly unsuccessful and depending on the size of the osteonecrosis result in biomechanical failure and ultimately subchondral insufficiency fractures (crescent sign), thus marking the transition to stage III ARCO (joint surface collapse).
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Affiliation(s)
- T Grieser
- Klinik für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
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28
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Performance of a Deep Learning Algorithm in Detecting Osteonecrosis of the Femoral Head on Digital Radiography: A Comparison With Assessments by Radiologists. AJR Am J Roentgenol 2019; 213:155-162. [PMID: 30917021 DOI: 10.2214/ajr.18.20817] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The objective of our study was to compare the sensitivity of a deep learning (DL) algorithm with the assessments by radiologists in diagnosing osteonecrosis of the femoral head (ONFH) using digital radiography. MATERIALS AND METHODS. We performed a two-center, retrospective, noninferiority study of consecutive patients (≥ 16 years old) with a diagnosis of ONFH based on MR images. We investigated the following four datasets of unilaterally cropped hip anteroposterior radiographs: training (n = 1346), internal validation (n = 148), temporal external test (n = 148), and geographic external test (n = 250). Diagnostic performance was measured for a DL algorithm, a less experienced radiologist, and an experienced radiologist. Noninferiority analyses for sensitivity were performed for the DL algorithm and both radiologists. Subgroup analysis for precollapse and postcollapse ONFH was done. RESULTS. Overall, 1892 hips (1037 diseased and 855 normal) were included. Sensitivity and specificity for the temporal external test set were 84.8% and 91.3% for the DL algorithm, 77.6% and 100.0% for the less experienced radiologist, and 82.4% and 100.0% for the experienced radiologist. Sensitivity and specificity for the geographic external test set were 75.2% and 97.2% for the DL algorithm, 77.6% and 75.0% for the less experienced radiologist, and 78.0% and 86.1% for the experienced radiologist. The sensitivity of the DL algorithm was noninferior to that of the assessments by both radiologists. The DL algorithm was more sensitive for precollapse ONFH than the assessment by the less experienced radiologist in the temporal external test set (75.9% vs 57.4%; 95% CI of the difference, 4.5-32.8%). CONCLUSION. The sensitivity of the DL algorithm for diagnosing ONFH using digital radiography was noninferior to that of both less experienced and experienced radiologist assessments.
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Differences in magnetic resonance findings between symptomatic and asymptomatic pre-collapse osteonecrosis of the femoral head. Eur J Radiol 2019; 112:1-6. [DOI: 10.1016/j.ejrad.2019.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/03/2019] [Indexed: 11/18/2022]
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Ikemura S, Mawatari T, Matsui G, Iguchi T, Mitsuyasu H. The depth of the low-intensity band on the T1-weighted MR image is useful for distinguishing subchondral insufficiency fracture from osteonecrosis of the collapsed femoral head. Arch Orthop Trauma Surg 2018; 138:1053-1058. [PMID: 29728832 DOI: 10.1007/s00402-018-2948-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 10/17/2022]
Abstract
PURPOSE To verify the hypothesis that depth of the low-intensity band on T1-weighted MR image is useful for distinguishing subchondral insufficiency fracture (SIF) from osteonecrosis of the collapsed femoral head (ON). PATIENTS AND METHODS We reviewed 35 consecutive hips in 35 patients with radiological evidence of subchondral collapse of the femoral head and available MR images and histology between May 2013 and January 2016. Both clinical and radiological appearances were investigated. The ratios of distance from articular surface of the femoral head to the T1 low-intensity band to femoral head diameter (band depth ratio: BDR) on (1) mid-coronal slice of MR images and that on (2) coronal slice of MR images in which the highest BDR was observed, were calculated. RESULTS The mean age in SIF group was significantly higher than that in ON group (SIF: 68 years, ON: 49 years, P = 0.0017). The rates of history of steroid intake or alcohol consumption in SIF group were significantly lower than those in ON group (P = 0.0022 and P = 0.0408, respectively). The mean BDRs in SIF group were (1) 0.16 and (2) 0.23, which were significantly lower than those in ON group [(1) 0.42 and (2) 0.59] (P < 0.0001 for both). The cut-off BDR values to differentiate SIF from ON were (1) 0.22 and (2) 0.38, respectively. CONCLUSION The results of the study suggest that depth of the low-intensity band on T1-weighted MR image is useful for distinguishing SIF from ON in cases with collapsed femoral heads.
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Affiliation(s)
- Satoshi Ikemura
- Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan.
| | - Taro Mawatari
- Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Gen Matsui
- Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Takahiro Iguchi
- Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
| | - Hiroaki Mitsuyasu
- Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan
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Arlachov Y, Ibrahem Adam R. Acute hip pain: mimics of a femoral neck fracture. Clin Radiol 2018; 73:773-781. [PMID: 29903428 DOI: 10.1016/j.crad.2018.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/09/2018] [Indexed: 11/18/2022]
Abstract
Acute hip pain is a common presenting complaint among patients attending Emergency Departments particularly following a traumatic event. A proximal femoral fracture is the main consideration, which requires urgent confirmation and treatment; however, there are a number of conditions, which could mimic neck of femur fracture and the causes may not be directly related to the hip, so systematic and careful observation of pelvic MRI could shed light on the true culprit of acute hip pain.
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Affiliation(s)
- Y Arlachov
- Department of Radiology, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NH5 1PB, UK.
| | - R Ibrahem Adam
- Department of Radiology, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NH5 1PB, UK
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Abstract
PURPOSE OF REVIEW The purpose of this paper is to review the distinct clinical and radiographic features that may lead to prompt diagnosis of rapidly progressive osteoarthritis (RPOA) and thus obviate unnecessary and costly diagnostic workup. RECENT FINDINGS RPOA is uncommon but is more frequently seen in practice because of the aging population. RPOA is a destructive arthropathy that occurs most commonly in elderly women but can also be seen in patients that have sustained trauma. The dramatic radiologic manifestations of RPOA can lead to diagnostic confusion with other arthropathies, infection, and osteonecrosis. RPOA was originally described in the hip but may also involve the shoulder. The etiology of RPOA is not well understood, but subchondral fracture probably plays a role in the development of dramatic destruction of the joint that is seen in affected patients. Early diagnosis may reduce the complexity of surgical management. RPOA is an uncommon condition that occurs most frequently in elderly woman or in patients who have sustained trauma. Prompt recognition of the clinical and radiologic features of this arthropathy can reduce unnecessary diagnostic workup and complexity of surgical intervention.
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Abe H, Sakai T, Ogawa T, Takao M, Nishii T, Nakamura N, Sugano N. Characteristics of bone turnover markers in rapidly destructive coxopathy. J Bone Miner Metab 2017; 35:412-418. [PMID: 27550182 DOI: 10.1007/s00774-016-0769-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 07/06/2016] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to clarify bone turnover marker levels in rapidly destructive coxopathy (RDC). Twenty patients with RDC (mean age, 72 ± 11 years; 3 men, 17 postmenopausal women), 111 with osteoarthritis (OA) (age, 60 ± 10 years; 15 men, 13 premenopausal women, 83 postmenopausal women), and 18 with osteonecrosis of femoral head (ON) (55 ± 14 years; 11 men, 3 premenopausal women, 4 postmenopausal women), and 100 patients with femoral neck fracture (FNF) (81 ± 10 years; 27 men, 73 postmenopausal women) were included. Serum tartrate-resistant acid phosphatase 5b (TRACP-5b), bone alkaline phosphatase (BAP), matrix metalloproteinase-3 (MMP-3) levels, and bone mineral density (BMD) of proximal femur and lumbar spine were investigated. TRACP-5b levels were significantly higher in RDC than in OA and ON, whereas BAP levels were higher in RDC than in OA (P < 0.05). MMP-3 levels were higher in RDC and ON than in OA (P < 0.05). TRACP-5b were higher in RDC than OA (P < 0.05) and FNF (P < 0.05) in performing propensity score matching; there were no differences in BMD between RDC and OA. TRACP-5b showed the largest area under the curve (AUC, 0.82) according to receiver operating characteristic (ROC) curve analysis for diagnosing RDC against OA and ON. AUCs of BAP and MMP-3 were 0.78 and 0.74. The respective sensitivities and specificities were 70.0 % and 85.3 % for TRACP-5b (cutoff, 623 mU/dl), 95.0 % and 57.1 % for BAP (13.8 U/l), and 70.0 % and 76.4 % for MMP-3 (52.7 ng/ml). The lack of differences in BMD suggested that high bone turnover marker levels may reflect osteoclast cell activation in RDC hips. Serum TRACP-5b and BAP could be RDC markers.
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Affiliation(s)
- Hirohito Abe
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takashi Sakai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 5650871, Japan.
| | - Takeshi Ogawa
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masaki Takao
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takashi Nishii
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | | | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Japan
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ACR Appropriateness Criteria Osteonecrosis of the Hip. J Am Coll Radiol 2016; 13:147-55. [PMID: 26846390 DOI: 10.1016/j.jacr.2015.10.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 10/30/2015] [Indexed: 12/16/2022]
Abstract
Osteonecrosis of the hip (Legg-Calvé-Perthes) is a common disease, with 10,000-20,000 symptomatic cases annually in the United States. The disorder affects both adults and children and is most frequently associated with trauma and corticosteroid usage. The initial imaging evaluation of suspected hip osteonecrosis is done using radiography. MRI is the most sensitive and specific imaging modality for diagnosis of osteonecrosis of the hip. The clinical significance of hip osteonecrosis is dependent on its potential for articular collapse. The likelihood of articular collapse is significantly increased with involvement of greater than 30%-50% of the femoral head area, which is optimally evaluated by MRI, often in the sagittal plane. Contrast-enhanced MRI may be needed to detect early osteonecrosis of the hip in pediatric patients, revealing hypoperfusion. In patients with a contraindication for MRI, use of either CT or bone scintigraphy with SPECT (single-photon emission CT) are alternative radiologic methods of assessment. Imaging helps guide treatment, which may include core decompression, osteotomy, and ultimately, need for joint replacement. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Kim SM, Oh SM, Cho CH, Lim SJ, Moon YW, Choi SH, Park YS. Fate of subchondral fatigue fractures of femoral head in young adults differs from general outcome of fracture healing. Injury 2016; 47:2789-2794. [PMID: 27771040 DOI: 10.1016/j.injury.2016.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/16/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to report the clinical course of fatigue-type subchondral fractures of the femoral head in young healthy adults. MATERIALS/METHODS We retrospectively reviewed 28 consecutive patients (34 hips) who had a clear history of a sudden increase in physical activity without trauma on the hip and pelvis, and were diagnosed as having a fatigue-type subchondral fracture of the femoral head. The diagnosis was made primarily on the basis of sequential plain radiographs and magnetic resonance images. RESULTS Of the 34 hips, 19 hips with no bony collapse experienced gradual disappearance of subjective pain a few months after onset, and there were no recurrences. Other 2 hips that showed bony collapse, but preserved the articular margin, also experienced no definite deterioration of collapse or arthritic change and did not need surgical intervention. In the remaining13 hips with bony collapse and destroyed articular margin or arthritic change, hip pain gradually worsened necessitating surgery. CONCLUSIONS The current findings suggest that a subchondral fatigue fracture of the femoral head could show a different severity of subchondral injury over time. In the collapsed subchondral fatigue fractures, especially when combined with head incongruency, the hip pain was aggravated enough to require surgical intervention.
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Affiliation(s)
- Sang-Min Kim
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Seung-Min Oh
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Chang-Ho Cho
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Seung-Jae Lim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wan Moon
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Hee Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Youn-Soo Park
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head. Skeletal Radiol 2016; 45:1515-21. [PMID: 27557789 DOI: 10.1007/s00256-016-2462-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 08/09/2016] [Accepted: 08/12/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Our aims were to investigate the imaging appearance of subchondral insufficiency fracture (SIF) of the femoral head based on fat-suppressed T2-weighted MRI, and evaluate its correlation with the clinical outcomes following conservative treatment. MATERIALS AND METHODS We retrospectively evaluated 40 hips in 37 patients with SIF of the femoral head (12 males and 25 females; mean age 55.8 years, range 22-78 years). MRI examinations were performed within 3 months after the onset of hip pain. Using fat-suppressed T2-weighted imaging, we evaluated the hips for the intensity of the subchondral bone (corresponding to the area superior to the low intensity band on T1-weighted images) as well as bone marrow edema, joint effusion, and presence of the band lesion. We then correlated the intensity of the subchondral bone with clinical outcomes. RESULTS The hips were classified into three types based on subchondral intensity on fat-suppressed T2-weighted images: type 1 (21 hips) showed high intensity, type 2 (eight hips) showed heterogeneous intensity, and type 3 (11 hips) showed low intensity. The mean period between pain onset and MRI examination was significantly longer for type 2 hips than for type 1. Healing rates were 86 % for type 1, 75 % for type 2, and 18 % for type 3. CONCLUSION SIF cases were classified into three types based on subchondral intensity on fat-suppressed T2-weighted imaging performed within 3 months after pain onset. Type 3 SIF tended to be intractable to conservative treatment compared to type 1 and type 2.
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Utsunomiya T, Yamamoto T, Motomura G, Hamai S, Iwamoto Y. The clinicopathologic findings of a subchondral insufficiency fracture of the femoral head in a male patient: a case report. Skeletal Radiol 2016; 45:1425-9. [PMID: 27480618 DOI: 10.1007/s00256-016-2443-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/13/2016] [Accepted: 07/18/2016] [Indexed: 02/02/2023]
Abstract
There are few reports describing the clinicopathologic characteristics of subchondral insufficiency fractures of the femoral head (SIF) in men over 50 years of age. A 59-year-old man experienced a sudden onset of the left hip pain without any antecedent trauma. The hip pain did not improve despite conservative treatments, and he underwent a total hip arthroplasty. The mid-coronal cut section of the resected femoral head revealed a fracture line paralleling the subchondral bone endplate beneath the articular cartilage. In addition, the subchondral fracture broadly underlaid the weight bearing area of the femoral head. Histopathologically, reparative tissue including fracture callus and granulation tissue, as well as thin disconnected bone trabeculae were observed. These clinicopathological findings were similar to those of previously described SIF in women. It is therefore important to consider SIF in cases of acute hip pain, even in middle-aged men.
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Affiliation(s)
- Takeshi Utsunomiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan.
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Goro Motomura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Satoshi Hamai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, 1-1 Sonekita-machi, Kokuraminami-ku, Kitakyushu City, 800-0296, Japan
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Jo WL, Lee WS, Chae DS, Yang IH, Lee KM, Koo KH. Decreased Lumbar Lordosis and Deficient Acetabular Coverage Are Risk Factors for Subchondral Insufficiency Fracture. J Korean Med Sci 2016; 31:1650-5. [PMID: 27550496 PMCID: PMC4999410 DOI: 10.3346/jkms.2016.31.10.1650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/07/2016] [Indexed: 11/20/2022] Open
Abstract
Subchondral insufficiency fracture (SIF) of the femoral head occurs in the elderly and recipients of organ transplantation. Osteoporosis and deficient lateral coverage of the acetabulum are known risk factors for SIF. There has been no study about relation between spinopelvic alignment and anterior acetabular coverage with SIF. We therefore asked whether a decrease of lumbar lordosis and a deficiency in the anterior acetabular coverage are risk factors. We investigated 37 patients with SIF. There were 33 women and 4 men, and their mean age was 71.5 years (59-85 years). These 37 patients were matched with 37 controls for gender, age, height, weight, body mass index and bone mineral density. We compared the lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope, acetabular index, acetabular roof angle, acetabular head index, anterior center-edge angle and lateral center-edge angle. Lumbar lordosis, pelvic tilt, sacral slope, lateral center edge angle, anterior center edge angle, acetabular index and acetabular head index were significantly different between SIF group and control group. Lumbar lordosis (OR = 1.11), lateral center edge angle (OR = 1.30) and anterior center edge angle (OR = 1.27) had significant associations in multivariate analysis. Decreased lumbar lordosis and deficient anterior coverage of the acetabulum are risk factors for SIF as well as decreased lateral coverage of the acetabulum.
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Affiliation(s)
- Woo Lam Jo
- Department of Orthopaedic Surgery, The Catholic University of Seoul St. Mary's Hospital, Seoul, Korea
| | - Woo Suk Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Dong Sik Chae
- Department of Orthopaedic Surgery, International St. Mary's Hospital, Incheon, Korea
| | - Ick Hwan Yang
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Min Lee
- Department of Orthopaedic Surgery, Seoul national University Bundang Hospital, Seongnam, Korea
| | - Kyung Hoi Koo
- Department of Orthopaedic Surgery, Seoul national University Bundang Hospital, Seongnam, Korea
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Ikemura S, Mawatari T, Matsui G, Iguchi T, Mitsuyasu H. Clinical outcomes in relation to locations of bone marrow edema lesions in patients with a subchondral insufficiency fracture of the hip: a review of fifteen cases. Br J Radiol 2016; 89:20150750. [PMID: 27537078 DOI: 10.1259/bjr.20150750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The prognosis of patients with a subchondral insufficiency fracture remains unclear. The purpose of this study was to investigate the correlation between locations of bone marrow edema (BME) lesions and clinical outcome in patients with a subchondral insufficiency fracture of the hip. METHODS We retrospectively reviewed 15 consecutive hips in 14 patients who were diagnosed with subchondral insufficiency fracture of the hip at our institution between April 2013 and September 2014. This study included five males (six hips) and nine females (nine hips), ranging from 36 to 83 years of age (mean age: 66 years). The mean duration from the onset of hip pain to MRI examination was 1.8 months (range 0.5-5 months). Both clinical and imaging findings were investigated. RESULTS Based on the findings of MR images, BME lesion in the femoral head alone was observed in six patients (six hips), BME lesion in the acetabulum alone was observed in one patient (two hips) and BME lesions in both the femoral head and acetabulum were observed in seven patients (seven hips). 3 of 15 hips resulted in rapidly destructive arthrosis and their BME lesions were observed in both the femoral head and acetabulum. 8 of 15 hips successfully healed by conservative treatment and BME lesions in 7 of these 8 hips were observed in only the femoral head or acetabulum. CONCLUSION The results of this study indicate that the locations of BME lesions (femoral side alone, acetabular side alone or both) may be related to the clinical outcome in patients with a subchondral insufficiency fracture of the hip. ADVANCES IN KNOWLEDGE Patients with subchondral insufficiency fracture of the hip in whom BME lesions were observed in both the femoral head and acetabulum may have a higher risk to need to undergo total hip arthroplasty.
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Affiliation(s)
- Satoshi Ikemura
- Department of Orthopaedic Surgery, Hamanomachi Hospital, Fukuoka, Japan
| | - Taro Mawatari
- Department of Orthopaedic Surgery, Hamanomachi Hospital, Fukuoka, Japan
| | - Gen Matsui
- Department of Orthopaedic Surgery, Hamanomachi Hospital, Fukuoka, Japan
| | - Takahiro Iguchi
- Department of Orthopaedic Surgery, Hamanomachi Hospital, Fukuoka, Japan
| | - Hiroaki Mitsuyasu
- Department of Orthopaedic Surgery, Hamanomachi Hospital, Fukuoka, Japan
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Kubo Y, Yamamoto T, Motomura G, Kido S, Karasuyama K, Sonoda K, Iwamoto Y. Transient epiphyseal lesion of the femoral head after traumatic hip dislocation: A case report. Int J Surg Case Rep 2016; 24:46-9. [PMID: 27179337 PMCID: PMC4873613 DOI: 10.1016/j.ijscr.2016.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/02/2016] [Accepted: 05/03/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION We experienced a rare case in which magnetic resonance imaging (MRI) showed a transient epiphyseal lesion of the femoral head four months after traumatic hip dislocation. To our knowledge, there have been no previously published reports on the development of such transient lesions after traumatic hip dislocation involving no abnormalities just after dislocation. PRESENTATION OF CASE We report a 22-year-old man who showed a transient epiphyseal lesion of the femoral head after traumatic hip dislocation. On MRI performed two days after dislocation, no bony injuries were observed around the hip joint. Four months after dislocation, the patient suddenly experienced right hip pain without any new trauma or injury. A low-intensity band convex to the articular surface was apparent above the epiphyseal scar on T1-weighted imaging, and bone marrow edema was observed around the band lesion on short-tau inversion recovery imaging. Following a two-month period of non-surgical conservative therapy, the patient's hip pain resolved and the low-intensity band was no longer observed on follow-up MRI. DISCUSSION Although the detailed pathogenesis of this transient changes was unclear, we speculate that prolonged rest after traumatic hip dislocation may contribute to bone insufficiency, resulting in an insufficiency fracture of the femoral head. CONCLUSION This study suggests that transient epiphyseal lesions of the femoral head may occur in patients with a history of traumatic hip dislocation associated with an adapted long-term rest.
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Affiliation(s)
- Yusuke Kubo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Goro Motomura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Satoshi Kido
- Department of Orthopaedic Surgery, Yamaguchi Red Cross Hospital, 53-1 Yahatababa, Yamaguchi 753-8519, Japan
| | - Kazuyuki Karasuyama
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kazuhiko Sonoda
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, 1-3-1, Kuzuharatakamatsu, Kokuraminami-ku, Kitakyushu 800-0296, Japan
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Abstract
Subchondral insufficiency fracture of the femoral head may be confused with osteonecrosis, mainly because of radiological overlap. SPECT/CT with Tc-99 m hydroxymethylene diphosphonate images in 7 patients with subchondral insufficiency fracture were retrospectively reviewed and compared with those from 11 patients with symptomatic early osteonecrosis. In all of the hips with subchondral insufficiency fracture, SPECT/CT showed increased uptake at the subchondral lesions of the femoral head. On the other hand, in all of the hips with osteonecrosis, absence of uptake was confirmed at the subchondral lesions. SPECT/CT may assist in differentiating subchondral insufficiency fracture from osteonecrosis.
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Ikemura S, Yamashita A, Harada T, Watanabe T, Shirasawa K. Clinical and imaging features of a subchondral insufficiency fracture of the femoral head after internal fixation of a femoral neck fracture: a comparison with those of post-traumatic osteonecrosis of the femoral head. Br J Radiol 2016; 89:20150725. [PMID: 26828970 DOI: 10.1259/bjr.20150725] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Recent articles have demonstrated that subchondral insufficiency fractures (SIFs) of the femoral head can occur following internal fixation of femoral neck fractures (FNFs), in addition to post-traumatic osteonecrosis (ON) of the femoral head. The purpose of this study was to determine the clinical and imaging features of SIF after internal fixation of FNFs compared with those of post-traumatic ON. METHODS We reviewed five hips in five patients, who received internal fixation for the treatment of FNF and were diagnosed as having SIF according to the shape of the low-intensity band on the T1 weighted MR image. Four hips of four patients with post-traumatic ON were compared with the SIF cases. Both the clinical and imaging findings were investigated. RESULTS There were no significant differences in the age, sex, body mass index, stage of FNF or duration from injury to surgery between SIF and post-traumatic ON. Regarding the prognosis, one of the five cases (20%) with SIF underwent prosthetic replacement owing to a progressive collapse of the femoral head. Two of the four cases (50%) with post-traumatic ON underwent prosthetic replacement. CONCLUSION The results of this study suggest that SIF should be considered a possible condition following the internal fixation of FNFs, and it is important to differentiate SIF from post-traumatic ON. ADVANCES IN KNOWLEDGE SIF should be considered a possible condition following the internal fixation of FNFs.
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Affiliation(s)
- Satoshi Ikemura
- Department of Orthopaedic Surgery, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Akihisa Yamashita
- Department of Orthopaedic Surgery, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Takashi Harada
- Department of Orthopaedic Surgery, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Tetsuya Watanabe
- Department of Orthopaedic Surgery, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Kenzo Shirasawa
- Department of Orthopaedic Surgery, Shimonoseki City Hospital, Shimonoseki, Japan
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Imaging of Hip Pain: From Radiography to Cross-Sectional Imaging Techniques. Radiol Res Pract 2016; 2016:6369237. [PMID: 26885391 PMCID: PMC4738697 DOI: 10.1155/2016/6369237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/17/2015] [Accepted: 12/20/2015] [Indexed: 12/16/2022] Open
Abstract
Hip pain can have multiple causes, including intra-articular, juxta-articular, and referred pain, mainly from spine or sacroiliac joints. In this review, we discuss the causes of intra-articular hip pain from childhood to adulthood and the role of the appropriate imaging techniques according to clinical suspicion and age of the patient. Stress is put on the findings of radiographs, currently considered the first imaging technique, not only in older people with degenerative disease but also in young people without osteoarthritis. In this case plain radiography allows categorization of the hip as normal or dysplastic or with impingement signs, pincer, cam, or a combination of both.
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Murphey MD, Foreman KL, Klassen-Fischer MK, Fox MG, Chung EM, Kransdorf MJ. From the radiologic pathology archives imaging of osteonecrosis: radiologic-pathologic correlation. Radiographics 2015; 34:1003-28. [PMID: 25019438 DOI: 10.1148/rg.344140019] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Osteonecrosis is common and represents loss of blood supply to a region of bone. Common sites affected include the femoral head, humeral head, knee, femoral/tibial metadiaphysis, scaphoid, lunate, and talus. Symptomatic femoral head osteonecrosis accounts for 10,000-20,000 new cases annually in the United States. In contradistinction, metadiaphyseal osteonecrosis is often occult and asymptomatic. There are numerous causes of osteonecrosis most commonly related to trauma, corticosteroids, and idiopathic. Imaging of osteonecrosis is frequently diagnostic with a serpentine rim of sclerosis on radiographs, photopenia in early disease at bone scintigraphy, and maintained yellow marrow at MR imaging with a serpentine rim of high signal intensity (double-line sign) on images obtained with long repetition time sequences. These radiologic features correspond to the underlying pathology of osseous response to wall off the osteonecrotic process and attempts at repair with vascularized granulation tissue at the reactive interface. The long-term clinical importance of epiphyseal osteonecrosis is almost exclusively based on the likelihood of overlying articular collapse. MR imaging is generally considered the most sensitive and specific imaging modality both for early diagnosis and identifying features that increase the possibility of this complication. Treatment subsequent to articular collapse and development of secondary osteoarthritis typically requires reconstructive surgery. Malignant transformation of osteonecrosis is rare and almost exclusively associated with metadiaphyseal lesions. Imaging features of this dire sequela include aggressive bone destruction about the lesion margin, cortical involvement, and an associated soft-tissue mass. Recognizing the appearance of osteonecrosis, which reflects the underlying pathology, improves radiologic assessment and is important to guide optimal patient management.
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Affiliation(s)
- Mark D Murphey
- From the Departments of Musculoskeletal Imaging (M.D.M., K.L.F., E.M.C.) and Pediatric Imaging (E.M.C.), American Institute for Radiologic Pathology, 1010 Wayne Ave, Suite 320, Silver Spring, MD 20910; Uniformed Services University of the Health Sciences, Bethesda, Md (M.D.M., E.M.C.); Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Md (M.D.M., K.L.F., E.M.C.); Joint Pathology Center, Silver Spring, Md (M.K.K.F.); Department of Radiology, University of Virginia, Charlottesville, Va (M.G.F.); and Mayo Clinic Hospital, Phoenix, Ariz (M.J.K.)
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Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am 2015; 97:1604-27. [PMID: 26446969 DOI: 10.2106/jbjs.o.00071] [Citation(s) in RCA: 308] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.
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Affiliation(s)
- Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for M.A. Mont:
| | - Jeffrey J Cherian
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for M.A. Mont:
| | - Rafael J Sierra
- Mayo Clinic, 200 First Street S.W., Gonda 14 South, Rochester, MN 55905
| | - Lynne C Jones
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 North Caroline Street, JHOC 5245, Baltimore, MD 21287
| | - Jay R Lieberman
- Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033
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Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. Current concepts on osteonecrosis of the femoral head. World J Orthop 2015; 6:590-601. [PMID: 26396935 PMCID: PMC4573503 DOI: 10.5312/wjo.v6.i8.590] [Citation(s) in RCA: 286] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/16/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
It is estimated that 20000 to 30000 new patients are diagnosed with osteonecrosis annually accounting for approximately 10% of the 250000 total hip arthroplasties done annually in the United States. The lack of level 1 evidence in the literature makes it difficult to identify optimal treatment protocols to manage patients with pre-collapse avascular necrosis of the femoral head, and early intervention prior to collapse is critical to successful outcomes in joint preserving procedures. There have been a variety of traumatic and atraumatic factors that have been identified as risk factors for osteonecrosis, but the etiology and pathogenesis still remains unclear. Current osteonecrosis diagnosis is dependent upon plain anteroposterior and frog-leg lateral radiographs of the hip, followed by magnetic resonance imaging (MRI). Generally, the first radiographic changes seen by radiograph will be cystic and sclerotic changes in the femoral head. Although the diagnosis may be made by radiograph, plain radiographs are generally insufficient for early diagnosis, therefore MRI is considered the most accurate benchmark. Treatment options include pharmacologic agents such as bisphosphonates and statins, biophysical treatments, as well as joint-preserving and joint-replacing surgeries. the surgical treatment of osteonecrosis of the femoral head can be divided into two major branches: femoral head sparing procedures (FHSP) and femoral head replacement procedures (FHRP). In general, FHSP are indicated at pre-collapse stages with minimal symptoms whereas FHRP are preferred at post-collapse symptomatic stages. It is difficult to know whether any treatment modality changes the natural history of core decompression since the true natural history of core decompression has not been delineated.
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Urakawa H, Hasegawa Y, Tsukushi S, Seki T, Kozawa E, Ishiguro N, Nishida Y. Subchondral Fracture of the Femoral Head in a High School Badminton Player: A Case Report. Curr Sports Med Rep 2015; 14:386-8. [PMID: 26359840 DOI: 10.1249/jsr.0000000000000189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Hiroshi Urakawa
- 1Department of Orthopaedic Surgery, Nagoya University Graduate School and School of Medicine, Showa-ku, Nagoya, Aichi 466-8550, Japan; and 2Department of Hip and Knee Reconstructive Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi 466-8550, Japan
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Hackney LA, Lee MH, Joseph GB, Vail TP, Link TM. Subchondral insufficiency fractures of the femoral head: associated imaging findings and predictors of clinical progression. Eur Radiol 2015; 26:1929-41. [PMID: 26334506 DOI: 10.1007/s00330-015-3967-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/11/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To characterize the morphology and imaging findings of femoral head subchondral insufficiency fractures (SIF), and to investigate clinical outcomes in relation to imaging findings. METHODS Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. Thirty-five patients had follow-up documentation allowing assessment of clinical outcome. Subgroup comparisons were performed using regression models adjusted for age and body mass index. RESULTS SIF were frequently associated with cartilage loss (35/47, 74.5 %), effusion (33/42, 78.6 %), synovitis (29/44, 66 %), and bone marrow oedema pattern (BMEP) (average cross-sectional area 885.7 ± 730.2 mm(2)). Total hip arthroplasty (THA) was required in 16/35 patients, at an average of 6 months post-MRI. Compared to the THA cohort, the non-THA group had significantly (p < 0.05) smaller overlying cartilage defect size (10 mm vs. 29 mm), smaller band length ratio and fracture diameters, and greater incidence of parallel fracture morphology (p < 0.05). Male gender and increased age were significantly associated with progression, p < 0.05. CONCLUSIONS SIF were associated with synovitis, cartilage loss, effusion, and BMEP. Male gender and increased age had a significant association with progression to THA, as did band length ratio, fracture diameter, cartilage defect size, and fracture deformity/morphology. KEY POINTS • Femoral head subchondral insufficiency fractures (SIF) frequently require total hip arthroplasty (THA). • SIF frequently coexist with synovitis, cartilage loss, and bone marrow oedema pattern. • SIF cartilage defect size, band length ratio, and fracture diameter/morphology can predict progression risk.
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Affiliation(s)
- Lauren A Hackney
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA.
| | - Min Hee Lee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA.,Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gabby B Joseph
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA
| | - Thomas P Vail
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA
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Mavrogenis AF, Flevas DA, Panagopoulos GN, Megaloikonomos P, Igoumenou V, Vottis C, Sakellariou V, Kontogeorgakos V. Rapid destructive arthritis of the hip revisited. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1115-20. [DOI: 10.1007/s00590-015-1676-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/25/2015] [Indexed: 10/23/2022]
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50
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Pierce TP, Jauregui JJ, Cherian JJ, Elmallah RK, Mont MA. Imaging evaluation of patients with osteonecrosis of the femoral head. Curr Rev Musculoskelet Med 2015; 8:221-7. [PMID: 26045084 DOI: 10.1007/s12178-015-9279-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Imaging modalities for the diagnosis of osteonecrosis (ON) of the femoral head have been studied extensively, but there have been few reports strictly addressing radiographic evaluation. The purpose of this report is to examine the use and role of (1) plain radiographs, (2) magnetic resonance imaging (MRI), (3) computerized tomography (CT), (4) bone scanning, and (5) positron emission topography (PET) for the diagnostic evaluation of ON. Plain radiographs are a mainstay in diagnosis but have very low sensitivity for early ON. MRI is the gold standard for diagnostic evaluation but may not identify subchondral fractures on collapse as well as CT scan or tomogram. Bone scanning should not be used for diagnosis due to its low sensitivity. PET scanning does not have a definitive role in diagnosis yet. Future research should focus on the role of new imaging technologies in evaluation.
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Affiliation(s)
- Todd P Pierce
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
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