Osteonecrosis of the femoral head

Analysis of the efficacy of drilling decompression autologous bone marrow and allogeneic bone grafting in the treatment of HIV-positive patients with early osteonecrosis of the femoral head

OBJECTIVE

To investigate the efficacy of treating patients with HIV-positive osteonecrosis of the femoral head using drilled decompression autologous bone marrow and allogeneic bone grafting.

METHODS

40 patients (44 hips) with early osteonecrosis of the femoral head treated by drilling decompression autologous bone marrow and allogeneic bone grafting since October 2015 were retrospectively analyzed, among which 20 patients (24 hips) were HIV-positive patients with early osteonecrosis of the femoral head, 16 males and 4 females, age 22-43 years, average 39.6 ± 10.18 years, and 20 patients (20 hips) in the same period HIV-negative early osteonecrosis of the femoral head patients, 13 males and 7 females, aged 48-78 years, mean 63.50 ± 7.94 years were negative controls. General information including ARCO stage, Harris score, VAS score, hematological indexes including CD4+ T lymphocyte count, and HIV viral load was recorded for all patients before surgery. All patients were operated on by drilling and decompression of the necrotic area, harvesting autologous iliac bone marrow with allogeneic bone, and bone grafting through the decompression channel. The patients were followed up regularly at 6, 12, and 24 months after surgery and annually thereafter, and the repair of the necrotic femoral head was observed by reviewing the frontal and lateral X-ray, CT or MRI of the hip joint, and the complications and functional recovery of the hip joint was counted and compared between the two groups.

RESULTS

All patients were followed up, and the ARCO stages in the HIV-positive group were stage I 2 hips, stage IIA 6 hips, stage IIB 8 hips, stage IIC 6 hips, and stage III 2 hips, with a follow-up time of 12 to 60 months and a mean of 24.6 months. In the negative control group, there were 3 hips in ARCO stage I, 7 hips in stage IIA, 5 hips in stage IIB, 3 hips in stage IIC, and 2 hips in stage III, and the follow-up time ranged from 13 to 62 months, with an average of 24.8 months. The Harris score and VAS score of the hip in both groups improved significantly at 6 months postoperatively compared with those before surgery (P < 0.001). The difference between the Harris score of the hip in the positive group at 24 months postoperatively compared with that at 6 months postoperatively was statistically significant, but the VAS score at 24 months postoperatively compared with that at 6 months postoperatively was not statistically significant. In the negative group, there was no statistically significant difference in the Harris score and VAS score of the hip at 24 months postoperatively compared with those at 6 months postoperatively. In the positive group, there was a trend of continuous increase in hip BMD from the beginning of the postoperative period (P < 0.001). There was no statistically significant difference between the negative group and the positive group at the 24 months postoperatively follow-up except for the Harris score, which was statistically significant (P < 0.001), and the VAS score, which was statistically insignificant. At the 24 months postoperatively follow-up, patients in both groups had good recovery of hip function, and no complications such as vascular and nerve injury and fracture occurred during the perioperative period and follow-up period, and no complications related to incisional infection and pulmonary infection occurred during hospitalization.

CONCLUSION

The treatment of early HIV-positive osteonecrosis of the femoral head patients with autologous bone marrow and allogeneic bone grafting by drilling and decompression to remove the tissue in the necrotic area of the femoral head can effectively stop the process of osteonecrosis of the femoral head and promoting femoral head repair in HIV-positive patients is a safe and effective method for treating HIV-positive patients with early osteonecrosis of the femoral head, and can effectively delay or postpone total hip replacement in patients.

A Graphene Oxide-based Assay for Sensitive Osteonecrosis of the Femoral Head (ONFH) related microRNA Detection via Exonuclease-III Assisted Dual Signal Cycle

Accurate detection of circulating microRNAs (miRNAs) plays a vital role in the diagnosis of various diseases. The current miRNA detection methods, however, are widely criticized for their low sensitivity and excessive background signal. Herein, we propose a graphene oxide (GO) based fluorescent biosensor for sensitive and reliable miRNA analysis with a low background signal by utilizing exonuclease III (Exo III)-assisted target recycling and hybridization chain reaction (HCR). To initiate Exo-III-assisted dual signal cycles, a hairpin DNA probe (H probe) was developed for selective miRNA binding. Dye quenching occurred when carboxyfluorescein (FAM)-labeled hairpins (HP1 and HP1) were unable to bind to their intended target and instead adsorb onto the surface of GO via p-stacking interactions. Exo III sequentially cleaved the 3'-strand of the H probe and the S probe upon attachment of the target miRNA, resulting in the release of the miRNA and the autonomous production of a "g" sequence. The released target miRNA then hybridized with a second H probe and progressed to the subsequent reaction phase. With the help of the HP1 and HP2 probes, a lengthy dsDNA product was produced when the "g" sequence triggered HCR. The dsDNA product was not absorbed by GO, and the material instead fluoresced brightly. As a result, the amount of miRNA of interest was measured. With a LOD of only 5.6 fM, this bioassay demonstrated excellent selectivity and great sensitivity.

The effects of MIR137HG genetic polymorphisms on the susceptibility of alcohol-induced osteonecrosis of the femoral head in a Chinese male population

BACKGROUNDS

Osteonecrosis of the femoral head (ONFH) is one of the common and complicated diseases in the orthopedic clinic. Previous studies indicate that genetic factors play a crucial role in the occurrence of ONFH. This case-control study aimed to investigate the associations of MIR137HG genetic polymorphisms with the alcohol-induced ONFH risk.

METHODS

A total of 731 participants were recruited to detect the effect of MIR137HG SNPs on the alcohol-induced ONFH risk in a Chinese male population. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to evaluate the associations. Multifactor dimensionality reduction (MDR) was used to analyze the SNP-SNP interaction with the alcohol-induced ONFH risk.

RESULTS

Our study showed that rs7549905 played a protective role in alcohol-induced ONFH risk (OR 0.57, p = 0.045). Stratified analysis indicated that rs9440302 was associated with an increased risk of patients aged >45 years (OR 2.00, p = 0.038), and rs7549905 showed a reduced risk in patients aged ≤ 45 years (OR 0.43, p = 0.023). In addition, we found that rs9440302 and rs7554283 exhibited a significantly increased susceptibility of III-IV grade alcohol-induced ONFH patients (OR 2.34, p = 0.003; OR 2.13, p = 0.011, respectively). We also observed that rs12138817 was related to an increased risk in patients with >21 months of course (OR 1.77, p = 0.043). Interestingly, rs17371457 showed a significant correlation with low-density lipoprotein-cholesterol (p = 0.040).

CONCLUSION

Our study suggests that MIR137HG genetic variants are associated with the alcohol-induced ONFH susceptibility in a Chinese male population, which may give scientific evidence for exploring molecular mechanisms of the alcohol-induced ONFH.

Evidence-Supported HBO Therapy in Femoral Head Necrosis: A Systematic Review and Meta-Analysis

Although many studies have shown that hyperbaric oxygen (HBO) therapy can significantly improve symptoms and quality of life of patients affected by femoral head necrosis, this therapy is not worldwide approved yet. This meta-analysis was performed to evaluate its clinical effect. Relevant studies published before May 2020 were systematically searched using terms related to HBO and femoral head necrosis. Fixed and random-effects models were used to estimate the odds ratio (OR) with 95% confidence intervals (CI). Subgroup analyses and publication bias tests were carried out to explore potential study heterogeneity and bias. Ten studies involving 353 controls and 368 HBO-treated cases were included, most of which were conducted on Asian population. The clinical effect in the HBO therapy group was 3.84 times higher than in the control group (OR = 3.84, 95% CI (2.10, 7.02), p < 0.00001). Subgroup analyses showed that the clinical effect of HBO therapy was statistically significant in the Asian subpopulation which represented most of the subjects (OR = 3.53, 95% CI (1.87, 6.64), p < 0.00001), but not in the non-Asian subpopulation, probably because of insufficient numerosity (OR = 7.41, 95% CI (0.73, 75.71), p = 0.09). The results of this meta-analysis suggest that patients with femoral head necrosis treated with HBO therapy can achieve a significant clinical improvement.

Long-term survival and clinical outcomes of non-vascularized autologous and allogeneic fibular grafts are comparable for treating osteonecrosis of the femoral head

Background

Osteonecrosis of the femoral head (ONFH) is a disabling disease, which often involves young patients. Recently, various hip-preserving surgeries were recommended to delay total hip arthroplasty (THA).

Questions/purposes

This study aimed to compare clinical outcomes and survival rate in the long-term follow-up between core decompression combined with a non-vascularized autologous fibular graft (group A) and an allogeneic fibular graft (group B) for the treatment of ONFH.

Patients and methods

We retrospectively evaluated 117 patients (153 hips) with ONFH (Association Research Circulation Osseous [ARCO] stages IIa to IIIc) who underwent the abovementioned hip-preserving surgeries between January 2003 and June 2012. The mean (range) follow-up times (years) were 12.9 (7–16) and 9.3 (6–16) in groups A and B, respectively. Clinical outcomes were assessed using the Harris Hip Score (HHS), visual analog scale (VAS) score, and forgotten joint score (FJS). A survival analysis was performed using the Kaplan-Meier method. The end point was THA.

Results

Groups A and B showed postoperative improvements, respectively, in HHS from 65 ± 7.2 to 80.3 ± 14.5 and from 66 ± 5.9 to 82.4 ± 13.6 (p < 0.05), and in VAS score from 6.3 ± 1.1 to 2.3 ± 1.6 and from 6.1 ± 1 to 2.2 ± 2.2 (p < 0.05). However, no significant differences in the HHS, VAS score, and hip FJS at the last follow-up (p > 0.05) and 15-year survival rate (84.1% and 86%, respectively, p > 0.05) were found between groups A and B.

Conclusions

Autologous and allogeneic fibular grafts can attain equally good clinical outcomes and high survival rates in long-term follow-up, and thus can greatly delay THA owing to good bone osseointegration and sufficient mechanical support. Notably, the ratio of failure will increase when patients were more than 37 years old.

Level of evidence

Level III, therapeutic study

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02246-3.

Comparison of core decompression and porous tantalum rod implantation with conservative treatment for avascular necrosis of the femoral head: A minimum 18 month follow-up study

Porous tantalum rod implantation is a novel surgical method that is used to treat avascular necrosis (AVN) of the femoral head (hip). In the present study, the results of core decompression and tantalum rod implantation were compared with non-surgical treatment for AVN, and the survivorship of the femoral head was evaluated. In total, 60 patients with AVN femoral head were recruited and analysed. Non-surgical treatment was selected by 30 patients (41 hips), 7 with a Ficat score of I and 23 with a score of II. Non-surgical treatment included celecoxib, salvia miltiorrhiza and tetramethylypyrazine and a reduction in weight-bearing activities. Surgical treatment and porous tantalum rod implantation were selected by 30 patients (41 hips), 10 with a Ficat score of I and 20 with a score of II. After follow-up (average: 33.5 months), patients were evaluated by assessing post-operative complications, radiology, hip survivorship and Harris hip score. In the surgical group, pre-operative symptoms were significantly alleviated. No complications, including infection, delayed healing or fractures were reported. Final follow-up rates of femoral head survivorship were 4.9% in the non-surgical group and 36.7% in the surgical group. The Harris hip score was significantly improved following surgery when compared with non-surgical treatment (P<0.05). The results indicated that core decompression and porous tantalum rod implantation are beneficial short- and mid-term treatment methods for AVN of the femoral head.

Effect of surgical treatment on the quality of life in patients with non-traumatic avascular necrosis of the femoral head

Objective

Avascular necrosis of the hip is a common debilitating disease during the fourth and fifth decades of life. This study attempted to evaluate quality of life in patients with avascular necrosis of the hip joint before and after surgery.

Methods

In this study, 40 patients with avascular necrosis of the hip who underwent total hip arthroplasty, bipolar surgery, or cord compression were examined during 2006–2013. Harris Hip Score was used to assess the hip joint function and quality of life before and after surgery. The mean scores and standard deviation were used to describe data for quantitative variables, while frequency percentage was used to describe qualitative variables. Data were analyzed through SPSS v.19 and paired t-test. p < 0.05 was considered significant.

Results

This study involved 40 subjects with a mean age of 32 ± 7.38 years, ranging from 21 to 45 years old. The mean Harris Hip Score for patients before and after surgery were 20.36 and 96.15, respectively, showing a statistically significant difference (p < 0.001). The average patient activity scores before and after surgery (8.9 and 44.2, respectively), non-deformity (1.6 and 3.9), and movement (3.6 and 4.9) indicated significant differences (p < 0.001). Furthermore, 80% of patients felt no hip joint pain six months after surgery, while 92.5% patients did not use any assistive device to walk.

Conclusions

The results of this study demonstrated that surgery substantially contributed to relieving pain and improving hip function in patients with osteonecrosis of the hip joint in the short term.

MRI-Guided Interventions in Musculoskeletal System

Image-guided interventions in the musculoskeletal system require accurate detection and characterization of lesions involving bone and soft tissues. Magnetic resonance imaging (MRI) has superior soft tissue contrast resolution particularly in bone and soft tissues where computed tomography and ultrasonography have significant limitations. In addition, the multiplanar imaging capabilities of MRI facilitate targeting lesions and tracking interventional devices. Although conventional diagnostic MRI sequences suffer from motion sensitivity and prolonged imaging time, recently developed fast imaging sequences allow for rapid acquisition of high-quality images, rendering MRI more suitable for image-guided interventions. Although computed tomography and ultrasonography still dominate the spectrum of image-guided interventions in the musculoskeletal system, many MRI-guided procedures have been developed and are well established in routine clinical work. In addition, new techniques and novel MRI-guided applications are being developed to address complex clinical problems in a minimally invasive fashion.

Association of eNOS polymorphisms with susceptibility to osteonecrosis of the femur head : A meta-analysis

OBJECTIVE

The aim of the present study was to determine whether polymorphisms of the endothelial nitric oxide synthase (eNOS) gene are associated with susceptibility to osteonecrosis of the femoral head (ONFH).

METHODS

We conducted a meta-analysis to assess the association between the 4b/a, G894T, and T786C polymorphisms of eNOS and the susceptibility to ONFH.

RESULTS

A total of five studies, which included 566 cases and 833 controls, were included in the meta-analysis. Meta-analysis revealed a significant association between allele a of the 4b/a polymorphism and ONFH in all study subjects (odds ratio, OR 3.237; 95 % confidence interval, CI 2.036-5.148; P = 6.9 × 10^-7); stratification by ethnicity indicated an association between this allele and ONFH in Caucasians and Asians (OR 2.985; 95 % CI 1.592-5.597; P = 0.001 and OR 3.567; 95 % CI 1.793-7.095; P = 2.9 × 10^-4, respectively). Meta-analysis stratified by ONFH type showed a significant association between allele a of the 4b/a polymorphism and idiopathic and secondary ONFH (OR 3.411; 95 % CI 2.049-5.679; P = 2.4 × 10^-6 and OR 3.163; 95 % CI 1.781-5.619, P = 8.6 × 10 ^-5, respectively). However, the meta-analysis did not show any allelic association between the G894T and T786C polymorphisms and ONFH (OR 1.718; 95 % CI 0.796-3.707; P = 0.168 and OR 1.027; 95 % CI 0.191-5.517; P = 0.976, respectively).

CONCLUSION

Our meta-analysis of published studies shows that the 4b/a polymorphism is associated with the development of idiopathic and secondary ONFH in Caucasians and Asians.

Administration of erythropoietin prevents bone loss in osteonecrosis of the femoral head in mice

Long-term administration of glucocorticoid hormones is considered one of predominant pathological factors inducing osteonecrosis of the femoral head (ONFH) development and progression, in which reduction of blood supply leads to a progressive bone loss and impairment of bone structure in the majority of cases. In a non-hematopoietic system, erythropoietin (EPO) can stimulate angiogenesis and bone regeneration. However, the specific mechanism underlying the role of EPO in ONFH remains to be elucidated. Therefore, the purpose of this study was to determine the effect of EPO on the prevention of bone loss in ONFH. Male C57BL/6J mice 3 months old were divided into two groups: EPO group and control groups. ONFH was established by the administration prednisolone (PDS, 100 mg/kg) with co-treatment of lipopolysaccharide (LPS, 1 mg/kg). ONFH mice received recombinant mouse EPO (500 U/kg/day) or saline intramuscularly. The mice were sacrificed at 2, 4, 6 and 8 weeks following the initiation of treatment. Alterations in the general architecture and histomorphology of the right femoral head were determined by hematoxylin and eosin staining and micro computed tomography (micro-CT). The expression of runt-related transcription factor 2 (Runx2), osteocalcin, vascular endothelial growth factor (VEGF) and platelet endothelial cell adhesion molecule (CD31) in the femoral head was tested by immunohistochemistry. Terminal deoxynucleotidyl-transferase-mediated dUTP nick end labeling (TUNEL) assay was performed to detect apoptosis in femoral heads. Micro-CT data revealed that EPO significantly improved bone volume/total volume and bone mineral density following 6 and 8 weeks of treatment. Histological analysis further demonstrated that EPO treatment improved the arrangement of trabeculae, thinning of trabeculae and other fractures in femoral heads, especially following 6 and 8 weeks of treatment. Immunohistochemical analysis suggested that EPO treatment up-regulated the expressions of Runx2, osteocalcin, VEGF and CD31 at 4 and 8 weeks. The TUNEL apoptosis assay suggested that EPO intervention reduced apoptosis in avascular ONFH. Therefore, EPO prevents bone loss in ONFH in mice through enhancing Runx2-mediated osteogenesis, VEGF-mediated angiogenesis and inhibition of cell apoptosis.

Influence of cigarette smoking on osteonecrosis of the femoral head (ONFH): a systematic review and meta-analysis

BACKGROUND

Current studies demonstrate controversy regarding the relationship between cigarette smoking and osteonecrosis of the femoral head (ONFH).

METHODS

We conducted a meta-analysis to evaluate the association between smoking and ONFH. Relevant articles published before September 2016 were identified by a systematic search of EMBASE and MEDLINE via Ovid. Summary odds ratios (OR) were calculated using random effects models, and study quality was assessed using a modified Newcastle-Ottawa scale.

RESULTS

102 citations were screened and 7 case-control studies were identified and included in the review. When compared with nonsmokers, current smokers had a higher risk of developing ONFH (OR 2.53; 95% confidence interval [CI] 1.68-3.79), as did former smokers (OR 1.82; 95% CI, 1.10-3.00). Within the group of current smokers, those classified as heavy smokers (with a daily number >20 cigarettes/day) demonstrated higher risks of ONFH (OR 2.03; 95% CI, 1.29-3.19), and light smokers classified as smoking <20 cigarettes/day, also demonstrated a higher risk of ONFH when compared with nonsmokers (OR 1.73; 95% CI, 1.06-2.83). When smoking was classified by pack-years, heavy smokers (>20 pack-years) were at a higher risk of ONFH (OR 2.26; 95% CI, 1.24-4.13), but no significant difference in risk was identified in light smokers (<20 pack-years) (OR 1.81; 95% CI, 0.88-3.71) when compared with nonsmokers.

CONCLUSIONS

Our meta-analysis showed that current smokers were at a higher risk of ONFH, this high risk can also be found in former smokers. And heavy cigarette smoking showed a higher risk of ONFH than light smoking.

Osteonecrosis detected by whole body magnetic resonance in patients with Hodgkin Lymphoma treated by BEACOPP

OBJECTIVES

The purpose of our retrospective review of prospectively acquired Whole Body Magnetic Resonance (WB-MRI) scans was to assess the incidence of osteonecrosis in patients who received different chemotherapies.

METHODS

We evaluated the WB-MRI scans performed on 42 patients with Hodgkin Lymphoma treated by three chemotherapy regimens (6ABVD, 2ABVD + 4BEACOPP, 2ABVD + 8BEACOPP), excluding patients with the main risk factors for osteonecrosis.

RESULTS

Six out of seven patients (86 %) who received eight BEACOPP and one out of five patients (20 %) treated by four BEACOPP presented osteonecrosis, with a statistically significant difference of frequency between the two groups of patients (p < 0.05); no injury has been reported in patients treated by only ABVD. Among a total of 48 osteonecrotic lesions observed, 48 % were detected in the knee; multifocal osteonecrosis were detected in six out of seven patients (86 %).

CONCLUSIONS

The development of osteonecrosis is strictly related to the chemotherapy protocol adopted and the number of cycles received, with a strong correlation between the dose of corticosteroids included in the BEACOPP scheme and this complication. WB-MRI can be considered as a helpful tool that allows detecting earlier osteonecrotic lesions in patients treated with corticosteroids.

KEY POINTS

• Osteonecrosis is a possible complication of patients with Lymphoma treated by chemotherapy. • Osteonecrosis is related to the corticosteroids included within the BEACOPP protocol. • WB-MRI allows detecting osteonecrotic lesions in patients treated with corticosteroids.

Effect of the stiffness of bone substitutes on the biomechanical behaviour of femur for core decompression

Core decompression is the most common procedure for treatment of the early stages of osteonecrosis of the femoral head. The purpose of this study was to compare the biomechanical performance of four different bone graft substitutes combined with core decompression. Subject-specific finite element models generated from computed tomography (CT) scan data were used for a comprehensive analysis. Two different contact conditions were simulated representing states of osseointegration at the interface. Our results showed that the use of a low-stiffness bone substitute did not increase the risk of femoral fracture in the early postoperative phase, but resulted in less micromotion and interfacial stresses than high-stiffness bone substitutes.

Logistic regression analysis of risk factors for femoral head osteonecrosis after healed intertrochanteric fractures

PURPOSE

To evaluate the potential risk factors of the development of femoral head osteonecrosis after healed intertrochanteric fractures.

METHODS

We retrospectively reviewed all patients who were operated upon with closed reduction and internal fixation for intertrochanteric fractures by our medical group from December 1993 to December 2012. Patients with healed fractures were identified. Age, gender, comorbidities favouring osteonecrosis, causes of injuries, fracture patterns, the location of the primary fracture line, time from injury to surgery, fixation methods, and the development of femur head osteonecrosis of these patients were summarised. Univariate and multivariate logistic regression analysis were performed to evaluate the correlation between potential risk factors and the development of femoral head osteonecrosis.

RESULTS

A total of 916 patients with healed intertrochanteric fractures were identified. Femoral head osteonecrosis was found in 8 cases (0.87%). According to the results of univariate logistic regression, a more proximal fracture line, fixation with dynamic hip screws and age were found to be statistically significant factors. The results of multivariate logistic regression analysis indicated that the statistically significant predictors of femoral head osteonecrosis were younger age (odds ratio [OR] = 17.103; 95% confidence interval [CI], 1.988-147.111), a more proximal fracture line (OR = 31.439; 95% CI, 3.700-267.119) and applying dynamic hip screw as the internal fixation (OR = 11.114; 95% CI, 2.064-59.854).

CONCLUSIONS

Regular follow-up is commended in young patients with a proximal fracture line who underwent closed reduction and internal fixation with dynamic hip screw, even though the bone had healed.

Managing AVN following internal fixation: treatment options and clinical results

Avascular necrosis (AVN) after internal fixation of intracapsular hip fractures is a progressive multifactorial disease that ultimately results in local ischemia with ensuing osteocyte necrosis and structural compromise. This disease can cause significant clinical morbidity and affects patients of any age, including young and active patients. Effective treatment of this condition among young adults is challenging due to their high functional demands. The aim of managing AVN is to relieve pain, preserve range of movement and improve function. Treatment methods vary depending on the stage of the disease and can be broadly categorised into two options, hip preserving surgery and hip arthroplasty. Although, hip preserving techniques are attractive in the young adult, they may alter the morphology of the proximal femur and make subsequent arthroplasty more challenging. Conversely, arthroplasty in the young adult may require repeat revision procedures throughout the patient's life. Current evidence suggests that modifications of prevailing treatments, in addition to new technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis. This review aims to summarise the options available for treatment of AVN in the young adult and review the clinical results.

Protective effects of total saponins of panax notoginseng on steroid-induced avascular necrosis of the femoral head in vivo and in vitro

This research was designed to investigate the protective effects of TSPN on steroid-induced avascular necrosis of the femoral head (ANFH) and the likely mechanisms of those effects. As an in vivo study, TSPN was shown to be protective against steroid-induced ANFH due to the upregulation of VEGF-A. Furthermore, TSPN attenuated the apoptosis of osteocytes and reduced the expression of Caspase-3 relative to the model group. As an in vitro study, TSPN exerted a concentration-dependent protective effect against apoptosis in MC3T3-E1 cells. Moreover, TSPN (at a dose of 100 μg/mL) significantly reversed the dexamethasone-induced augmentation of Caspase-3 expression and activity. Therefore, our study demonstrated that TSPN had a protective effect against steroid-induced ANFH that was related to the upregulation of VEGF-A and the inhibition of apoptosis and Caspase-3 activation.

Fast sequences MR imaging at the investigation of painful skeletal sites in patients with hip osteonecrosis

BACKGROUND

Multiple osteonecrotic foci can be clinically silent when located in metaphyses and becomes painful when it affects juxta-articular areas. The purpose of this study was to assess the value of fast MR imaging to depict the underlying pathology in cases with skeletal pain other than the already diagnosed hip osteonecrosis.

METHODS/DESIGN

Between 2008 and 2013, 49 patients with already diagnosed hip osteonecrosis reported symptoms of deep skeletal pain in an anatomical site different from the affected hip joint. All patients after thorough history & clinical examination underwent evaluation with x-rays and a single fat suppressed sequence with MR Imaging applying either T2-w TSE or STIR-TSE at the painful site. False positive and false negative findings were recorded for the conventional x-rays and compared to MRI.

DISCUSSION

Forty four (89.8%) patients were positive for osteonecrotic lesions in this study and 76 symptomatic osteonecrosis lesions were revealed at 14 distinct anatomic sites. The agreement between the x-ray findings and the MR imaging regarding osteonecrosis was 46.9%. Plain x-rays showed 43.4% sensitivity, 100% specificity, 100% positive predictive value and 10.4% negative predictive value. Fast MR imaging with fat suppressed sequences is necessary and adequate as a single method for the investigation of painful skeletal sites in patients with already diagnosed hip osteonecrosis. It allows early diagnosis of the potentially debilitating multiple juxta-articular lesions and consequently their prompt management.

Management of femoral head osteonecrosis: Current concepts

Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.

Cajan leaf combined with bone marrow-derived mesenchymal stem cells for the treatment of osteonecrosis of the femoral head

The aim of the present study was to observe the curative effect of traditional Chinese cajan leaves, combined with administration of bone marrow-derived mesenchymal stem cells (BMSCs), on osteonecrosis of the femoral head (ONFH) in rats and to investigate the underlying mechanisms. A total of 40 rat ONFH models were established through liquid nitrogen freezing and were subsequently divided into groups: A, control; B, treated with cajan leaf; C, treated with BMSCs and D, treated with cajan leaf combined with BMSCs. Samples were obtained 30 days following treatment, and immunohistochemical staining of vascular endothelial growth factor (VEGF) and image analysis were performed. Chondrocytes and vascular endothelial cells were stained as a result of immunohistochemical staining and group D exhibited markedly deeper staining, and a significantly larger number of stained cells, compared with group A. Thus, in the present study, cajan leaf combined with BMSCs was shown to promote VEGF expression and improve ONFH repair.

The association of eNOS gene polymorphism with avascular necrosis of femoral head

Objectives

Necrosis of femoral head is a severe pathological state with multiple etiologies. This study investigated the association of the 27-bp repeat polymorphism in intron 4 and G894T polymorphism in exon 7 of the endothelial nitric oxide synthase (eNOS) gene with the pathogenesis of avascular necrosis of femoral head (ANFH).

Methods

A total of 125 non-traumatic ANFH patients and 126 healthy controls were recruited for this study. The 27-bp repeat polymorphisms in intron 4 were analyzed by polymerase chain reaction (PCR) and sequencing. The G894T polymorphisms in exon 7 were analyzed by PCR– restriction fragment length polymorphism (PCR-RFLP) analysis.

Results

All alleles were observed in non-traumatic ANFH patients and control subjects. Both ANFH patients and idiopathic subgroup of ANFH patients showed higher frequency of the 4a/b genotype than controls (p  = 0.001 and p  = 0.020, respectively). Significantly higher frequency of G/T genotype was observed in ANFH patients and idiopathic subgroup of ANFH patients compared to controls (p  = 0.009 and p  = 0.035, respectively).

Conclusion

eNOS gene polymorphisms may be a risk factor for ANFH. The 27-bp repeat polymorphism in intron 4, G894T polymorphism in exon 7, and subsequently reduced eNOS activity may be involved in the etiology of idiopathic ANFH.

Can local Erythropoietin administration enhance bone regeneration in osteonecrosis of femoral head?

Osteonecrosis of femoral head (ONFH) is a challenging disease. Regardless of underlying causes, the ultimate result in all cases is disruption of femoral head blood supply. Once the disease starts, it is progressive in 80% of cases. Since the majority of the affected individuals are young, every effort should be focused on preserving the patients own femoral head. These years, the role of angiogenic growth factors has been investigated with promising results in animal models of ONFH. Erythropoietin (EPO) is a well known hormone that has been used in treatment of chronic anemia for many years with few side effects. Considering the angiogenic properties of EPO, we hypothesize that local delivery of recombinant human EPO during core decompression will enhance bone regeneration in ONFH. In this way we also can avoid systemic side effects of EPO.