Patient's Perspective on Psychiatric Drugs: A Multicenter Survey-Based Study

OBJECTIVE

We aimed to identify the expectations and preferences for medication and medical decision-making in patients with major psychiatric disorders.

METHODS

A survey was conducted among patients with major psychiatric disorders who visited psychiatric outpatient clinics at 15 hospitals between 2016 and 2018 in Korea. The survey consisted of 12 questions about demographic variables and opinions on their expectations for medication, important medical decision-makers, and preferred drug type. The most preferred value in each category in the total population was identified, and differences in the preference ratio of each item among the disease groups were compared.

RESULTS

A total of 707 participants were surveyed. In the total population, patients reported high efficacy (44.01%±21.44%) as the main wish for medication, themselves (37.39%±22.57%) and a doctor (35.27%±22.88%) as the main decision makers, and tablet/capsule (36.16%±30.69%) as the preferred type of drug. In the depressive disorders group, the preference ratio of high efficacy was significantly lower, and the preference ratio of a small amount was significantly higher than that of the psychotic disorder and bipolar disorder groups. The preference ratio of a doctor as an important decision maker in the bipolar disorder group was higher compared to the other groups.

CONCLUSION

This study revealed the preference for medications and showed differences among patients with psychiatric disorders. Providing personalized medicine that considers a patient's preference for the drug may contribute to the improvement of drug compliance and outcomes.

Lethality-Associated Factors in Deliberate Self-Poisoning

Objectives

Deliberate self-poisoning (DSP) is the most common suicide method and can be life-threatening. The purpose of this study was to investigate the factors related to the lethality of DSP and the characteristics of the adolescent group.

Methods

A retrospective study was conducted on patients who had visited an academic hospital’s regional emergency medical center between 2015 and 2018. The data reviewed through their medical records included sociodemographic factors, clinical variables, and psychiatric treatment. Four groups (Q1–Q4) were categorized by descriptive analysis using the risk-rescue rating scale.

Results

A total of 491 patients were enrolled in this study. This study showed that high lethality had statistically significant associa-tions with male sex, older age, admitting suicidal intentions, and the use of herbicides for suicide. Logistic regression analyses showed a significant association between high-lethality and female [odds ratio (OR)=0.50, 95% confidence interval (CI)=0.30–0.81, p=0.01], non-psychiatric drugs (over-the-counter drug: OR=2.49, 95% CI=1.08–5.74, p=0.03; herbicide: OR=8.65, 95% CI=3.91–19.13, p<0.01), and denial of suicide intent (OR=0.28, 95% CI=0.15–0.55, p<0.01).

Conclusion

This study showed the clinical factors associated with the high lethality of DSP and suggested that efforts were needed to care for and thoroughly examine patients with DSP.

Relationship between Psychological Correlates and Empathy in Medical Students: A Cross-Sectional Study

OBJECTIVE

Empathy is important in the education of medical students. Many psychosocial variables are related to empathy. The aim of the study was to investigate the relationship between empathy and psychosocial factors such as burnout, personality, self-esteem, and resilience.

METHODS

The participants completed a set of self-reporting questionnaires, including questions related to socio-demographic characteristics, the Korean edition of the Jefferson Scale of Empathy, student version (JSE-S-K), Maslach Burnout Inventory General Survey (MBIGS), NEO Five-Factor Inventory (NEO-FFI), Rosenberg Self-esteem Scale (R-SES), and Connor-Davidson Resilience Scale (CD-RISC). Partial correlation and regression analyses were performed.

RESULTS

In male students, there were positive correlations between JSE-S-K and R-SES (r=0.229, p=0.002); conscientiousness of the NEO-FFI (r=0.153, p=0.037) and negative correlations, specifically between JSE-S-K and depersonalization of MBI (r=-0.206, p=0.005). In female students, there was positive correlations between JSE-S-K and personal accomplishment of MBI (r=0.384, p=0.004). In the multiple regression model, the JSE-S-K was affected by conscientiousness of the NEO-FFI (adjusted R2 =0.245, β=0.201, p=0.001); depersonalization, personal accomplishment of the MBI-GS (β=-0.188, p=0.001, β=0.143, p=0.017); R-SES (β=0.176, p=0.004); sex (β=0.117, p=0.029).

CONCLUSION

The present findings suggested that conscientiousness, depersonalization, personal accomplishment, self-esteem and sex have an influence on empathy. Therefore, these must be considered in medical education and can be helpful to nurture more empathetic doctors.

Current prescription pattern of maintenance treatments for bipolar patients in Korea: A focus on the transition from acute treatments

AIMS

We examined prescription patterns in maintenance treatment for recovered bipolar patients and compared these with acute treatments.

METHODS

Using retrospective methods, the bipolar patients in clinical recovery (Clinical Global Impression Bipolar Version score ≤ 2 for 6 months) after acute episode were selected. We reviewed differences between prescription patterns at remission and after a maintenance period of at least 6 months.

RESULTS

A total of 340 bipolar disorder patients were selected. During the maintenance period, more than half of the patients (192, 56.5%) took a mood stabilizer (MS) + antipsychotic (AP) combination. Among the MS, valproate (149, 43.8%) was most prescribed, and lithium (98, 28.8%) was second, but as patients moved into maintenance treatment, lithium use decreased, and the use of lamotrigine (86, 25.3%) increased. Preferred AP were quetiapine (125, 36.8%), aripiprazole (67, 19.7%), risperidone (48, 14.1%), and olanzapine (39, 11.5%). The use of olanzapine in maintenance was greatly decreased compared with that during acute treatment (67, 19.7%). Most patients did not take an antidepressant (AD), but the proportion using one or more AD was increased during maintenance (17.9% to 30.3%), and bupropion (28, 8.2%) was the preferred AD. Doses were decreased in all drugs, but lamotrigine was maintained at a dose of 133.2 ± 68.5 mg/day.

CONCLUSIONS

The most common prescription combination for bipolar maintenance treatment was MS + AP. The use of AP was decreased, whereas the use of AD in combination with MS and/or AP was increased. The doses of MS and AP were generally decreased during the maintenance periods, with the exception of lamotrigine.

Prevalence of Depressive Disorder of Outpatients Visiting Two Primary Care Settings

OBJECTIVES

Although the prevalence of depressive disorders in South Korea's general population is known, no reports on the prevalence of depression among patients who visit primary care facilities have been published. This preliminary study was conducted to identify the prevalence of depressive disorder in patients that visit two primary care facilities.

METHODS

Among 231 consecutive eligible patients who visited two primary care settings, 184 patients consented to a diagnostic interview for depression by psychiatrists following the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. There were no significant differences in sociodemographic characteristics such as gender, age, or level of education between the groups that consented and declined the diagnostic examination. The prevalence of depressive disorder and the proportion of newly diagnosed patients among depressive disorder patients were calculated.

RESULTS

The prevalence of depressive disorder of patients in the two primary care facilities was 14.1% (95% confidence interval [CI], 9.1 to 19.2), with major depressive disorder 5.4% (95% CI, 2.1 to 8.7), dysthymia 1.1% (95% CI, 0.0 to 2.6), and depressive disorder, not otherwise specified 7.6% (95% CI, 3.7 to 11.5). Among the 26 patients with depressive disorder, 19 patients were newly diagnosed.

CONCLUSIONS

As compared to the general population, a higher prevalence of depressive disorders was observed among patients at two primary care facilities. Further study is needed with larger samples to inform the development of a primary care setting-based depression screening, management, and referral system to increase the efficiency of limited health care resources.

Efficacy and Tolerability of Generic Mirtazapine (Mirtax) for Major Depressive Disorder: Multicenter, Open-label, Uncontrolled, Prospective Study

OBJECTIVE

Mirtax is a generic mirtazapine widely used since 2003. We conducted an open-label, uncontrolled 6-week study to evaluate the efficacy and safety of Mirtax for major depressive disorder (MDD).

METHODS

Ninety three MDD patients with the diagnosis of MDD and 17-item Hamilton Depression Rating Scale (HDRS) score ≥14 were recruited. The HDRS, Montgomery-Åsberg Depression Rating Scale (MADRS), and the Clinical Global Impressions-Severity Scale (CGI-S) were administered at baseline, 1, 2, 4 and 6 weeks. Response (≥50% decrease in the HDRS or MADRS score), remission (absolute HDRS score ≤7 or MADRS score ≤10) and CGI-I score ≤2 were also calculated. Adverse event (AE) frequency and severity, weight, blood pressure, and pulse rate were checked to assess safety.

RESULTS

The starting dosage was 11.5±6.4 mg/day, and the maintenance dosage was 23.1±9.4 mg/day. During 6 weeks, HDRS, MADRS and CGI-S scores decreased from 25.1±5.6 to 11.9±8.6 (mean change -13.1±8.3, p<0.001), from 30.2±6.3 to 13.73±10.40 (mean change -16.5±9.8, p<0.001), and from 5.0±0.8 to 2.5±1.3 (mean change -2.5±1.3, p<0.001), respectively. The percentages of responders, remitters by HDRS and patients with a CGI-I score ≤2 were 64.6%, 35.4% and 52.7%, respectively. Significant decreases in HDRS, MADRS and CGI-S scores were confirmed at week 1. The total rate of AEs was 32.3%; the most frequently reported AEs were sedation (4.3%) and constipation (4.3%). Weight was increased from 58.8±10.6 to 60.3±9.3 kg (mean change 0.7±1.7 kg, p=0.004).

CONCLUSION

This study, as the first clinical trial of generic mirtazapine, demonstrated the efficacy and tolerability of Mirtax for MDD using a single treatment design.

The Korean Medication Algorithm for Depressive Disorder: second revision

AIM

This study constitutes a revision of the guidelines for the treatment of major depressive disorder (MDD) issued by the Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) 2006. In incorporates changes in the experts׳ consensus that occurred between 2006 and 2012 as well as information regarding newly developed and recently published clinical trials.

METHODS

Using a 44-item questionnaire, an expert consensus was obtained on pharmacological treatment strategies for (1) non-psychotic MDD, (2) psychotic MDD, (3) dysthymia and depression subtypes, (4) continuous and maintenance treatment, and (5) special populations; consensus was also obtained regarding (6) the choice of an antidepressant (AD) in the context of safety and adverse effects, and (7) non-pharmacological biological therapies.

RESULTS

AD monotherapy was recommended as the first-line strategy for nonpsychotic depression in adults, children and adolescents, elderly adults, and patients with postpartum depression or premenstrual dysphoric disorder. The combination of AD and atypical antipsychotics (AAP) was recommended for psychotic depression. The duration of the initial AD treatment for psychotic depression depends on the number of depressive episodes. Most experts recommended stopping the initial AD and AAP therapy after a certain period in patients with one or two depressive episodes. However, for those with three or more episodes, maintenance of the initial treatment was recommended for as long as possible. Monotherapy with various selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) was recommended for dysthymic disorder and melancholic type MDD.

CONCLUSION

The pharmacological treatment strategy of KMAP-DD 2012 is similar to that of KMAP-DD 2006; however, the preference for the first-line use of AAPs was stronger in 2012 than in 2006.

A diagnosis of bipolar spectrum disorder predicts diagnostic conversion from unipolar depression to bipolar disorder: a 5-year retrospective study

BACKGROUND

The major aims of this study were to identify factors that may predict the diagnostic conversion from major depressive disorder (MDD) to bipolar disorder (BP) and to evaluate the predictive performance of the bipolar spectrum disorder (BPSD) diagnostic criteria.

METHODS

The medical records of 250 patients with a diagnosis of MDD for at least 5 years were retrospectively reviewed for this study.

RESULTS

The diagnostic conversion from MDD to BP was observed in 18.4% of 250 MDD patients, and the diagnostic criteria for BPSD predicted this conversion with high sensitivity (0.870) and specificity (0.917). A family history of BP, antidepressant-induced mania/hypomania, brief major depressive episodes, early age of onset, antidepressant wear-off, and antidepressant resistance were also independent predictors of this conversion.

LIMITATIONS

This study was conducted using a retrospective design and did not include structured diagnostic interviews.

CONCLUSIONS

The diagnostic criteria for BPSD were highly predictive of the conversion from MDD to BP, and conversion was associated with several clinical features of BPSD. Thus, the BPSD diagnostic criteria may be useful for the prediction of bipolar diathesis in MDD patients.

Age-related differences in suicidality between young people and older adults with depression: data from a nationwide depression cohort study in Korea (the CRESCEND study)

This study compared young people and older adults with depression to identify differences in suicidality between these groups. A total of 1003 patients with moderate to severe depression (Hamilton Depression Rating Scale [HDRS] score ≥14) were recruited from a national sample of 18 hospitals. Of the patients included in this study, 103 (10.3%) were placed in the younger group (age <25years) and 900 (89.7%) were placed in the older group (age ≥25years). Suicide-related variables and predictive factors associated with significant suicidal ideation were compared between the two groups. Regardless of the severity of depression, subjects in the younger group were more likely than were those in the older group to report significant suicidal ideation (scores ≥6 on the Beck Scale for Suicide Ideation [SSI-B], 79.6 vs. 53.7%, respectively; p<0.001), have had a suicide attempt at the current episode (4.9 vs. 1.6%, respectively; p=0.037), and have a history of suicide attempts (43.7 vs. 19.4%, respectively; p<0.001). Logistic regression models revealed that, in contrast to the predictive factors in the older group, subjects in the younger group were more affected by their history of suicide attempts (OR [95% CI]: 12.4, [1.5-99.1]; p=0.018) and depressive episodes (OR [95% CI]: 13.0, [1.6-104.0]; p=0.016). Also in contrast to the older group, an increase in HDRS score was not identified as a possible precipitating factor of significant suicidal ideation in younger subjects. The present findings demonstrate that suicidality in depressed young people was more severe than in older adults, but that suicidality was not correlated with the severity of depression. These data suggest that close attention should be paid to young people even in mild or moderate depression.

Relationship of temperament and character in remitted depressed patients with suicidal ideation and suicide attempts--results from the CRESCEND study

The aim of this study was to evaluate the Temperament and Character Inventory (TCI) scores of a sample of Korean patients with remitted depression who had attempted suicide and reported suicidal ideation and to compare their scores with those of remitted depressed patients without suicidal ideation. Adult depression patients who had completed 12 weeks of follow-up (N = 138) were divided into three groups: patients with a history of suicide attempts (N = 23); patients with current suicidal ideation (N = 59); and patients without current suicidal ideation (N = 56). After controlling for covariates, no significant differences were found among the three groups on any measure of temperament or character except self-directedness and self-transcendence. The self-transcendence scores of the lifetime suicide-attempt group were significantly higher compared with those of the suicidal-ideation group; post hoc analysis revealed that self-directedness was significantly lower in the suicide-attempt group compared with the non-suicidal group. The results from the present study suggest that remitted depression patients with a history of suicide attempts do not differ from non-attempters in temperament, but do differ in certain character traits.

How does antiepileptic drug induce suicidality? A case associated with levitracetam use

New antiepileptic drugs have been known to increase the risk of suicide. Among them, levitracetam is a widely used antiepileptic drug approved as a monotherapy treatment for partial seizures or as an adjunctive therapy for partial, myoclonic and generalized tonic-clonic seizures. It has been reported that the incidence of suicidal ideation during treatment with levitracetam was about 0.5-0.7%, but an explanation regarding a mechanism by which it causes suicidality is lacking. We made a multifaceted approach using the Hamilton Depression Rating Score (HDRS), the Hamilton Anxiety Rating Score (HARS), the Beck Hopelessness Scale (BHS), the Barratt Impulsiveness Scale (BIS), the Beck Scale for Suicidal Ideation (BSS) ideation daily and the Sheehan Suicidality Tracking Scale (SSTS) weekly in a patient taking levitracetam who acutely developed suicidal ideation after starting the medication. Suicidal ideation disappeared within 5 days of levitracetam discontinuation. We found that decreasing HDRS and BHS scores were correlated with BSS and SSTS scores. On the other hand, HARS and BIS did not change from their baselines. Our findings suggest that suicidality induced by an antiepileptic drug may be related to depression rather than anxiety and impulsiveness.

Does comorbid subthreshold anxiety predict treatment response in depression? Results from a naturalistic cohort study (the CRESCEND study)

OBJECTIVE

To investigate whether the anxious depression defined as depression with clinically significant anxiety but not comorbid anxiety disorder predicts poor outcomes of depression treatment in naturalistic clinical setting.

METHOD

From nationwide sample of 18 hospitals, 674 patients with moderate to severe depression who completed the DSM-IV-based Structured Clinical Interview (SCID) were recruited. Anxious depression was defined as not having comorbid anxiety disorder by SCID and having a Hamilton Rating Scale for Anxiety (HAM-A) total score ≥ 20. Participants were classified into three groups: anxious depression (N=259), non-anxious depression (N=351), or comorbid anxiety disorder (N=64). Rates of and time to remission and response and changes in scale scores were compared between these groups during 12 weeks treatment with antidepressant interventions freely determined by clinicians.

RESULTS

No significant differences were observed in the Hamilton Rating Scale for Depression (HAM-D) remission rate and the time to achieve HAM-D remission between anxious and non-anxious depression after adjustment for variables is not equally distributed at baseline. There were also no significant differences in HAM-D and HAM-A response rate and time to responses between two groups. Patients with comorbid anxiety disorder showed less improvement on HAM-D and HAM-A score than did those with anxious depression despite similar baseline symptom severity.

LIMITATION

This study was observational, and the treatment modality was naturalistic.

CONCLUSIONS

Anxious depression did not predict worse outcome to antidepressants treatment. This finding might result from exclusion of comorbid anxiety disorder from anxious depression population and allowance of broad treatment modality.

Korean medication algorithm for depressive disorder: comparisons with other treatment guidelines

We aimed to compare the recommendations of the Korean Medication Algorithm Project for Depressive Disorder 2012 (KMAP-DD 2012) with other recently published treatment guidelines for depressive disorder. We reviewed a total of five recently published global treatment guidelines and compared each treatment recommendation of the KMAP-DD 2012 with those in other guidelines. For initial treatment recommendations, there were no significant major differences across guidelines. However, in the case of nonresponse or incomplete response to initial treatment, the second recommended treatment step varied across guidelines. For maintenance therapy, medication dose and duration differed among treatment guidelines. Further, there were several discrepancies in the recommendations for each subtype of depressive disorder across guidelines. For treatment in special populations, there were no significant differences in overall recommendations. This comparison identifies that, by and large, the treatment recommendations of the KMAP-DD 2012 are similar to those of other treatment guidelines and reflect current changes in prescription pattern for depression based on accumulated research data. Further studies will be needed to address several issues identified in our review.

Gender and age differences in the impact of overweight on obesity-related quality of life among Korean adults

SUMMARY

OBJECTIVE

To investigate gender and age difference in impact of overweight on health-related quality of life (HRQOL) among Korean adults.

METHODS

Cross-sectional obesity-related quality of life (QOL) scores were measured by a Korean obesity-related QOL scale (KOQOL) from 448 Korean adults aged 20-80 years. A body mass index (BMI) was categorized with normal-weight as BMI < 23 kg/m(2), overweight as BMI ≥ 23 kg/m(2) based on the alternative cutoff points for Asians. Each gender was respectively stratified by median age, 45 years for men and 50 years for women, to examine the obesity-related QOL by age groups.

RESULTS

Women had a poorer obesity-related QOL compared to men (p < 0.001). In the younger age group, overweight women had a poorer obesity-related QOL compared with normal-weight women (p < 0.001), however normal-weight and overweight men showed no difference in obesity-related QOL. In the older age group, overweight men showed better QOL on the domains of work-related and psychosocial health than those for normal-weight men, but overweight women still suffered from work-related and routine life QOL.

CONCLUSIONS

This study showed the impact of overweight on obesity-related QOL was different for gender and age group. We should consider the results to manage weight in overweight persons.

Low serum vitamin D level is associated with high risk of metabolic syndrome in post-menopausal women

BACKGROUND

Serum vitamin D status, as indicated by 25-(OH)D, is inversely associated with glucose homeostasis, lipid profiles, and blood pressure. Evidence on the association of serum vitamin D with metabolic syndrome (MS) however, is very limited in post-menopausal women.

AIM

To investigate the association between serum vitamin D and MS.

MATERIALS AND METHODS

This study was a crosssectional study including 778 Korean adults who visited a health promotion center in a university hospital from January 2010 to May 2011. MS was defined according to the American Heart Association/National Heart, Lung, and Blood Institute criteria and the Korean Society for the Study of Obesity. MS and its individual components were assessed, as well as serum 25-(OH)D levels with a multiple logistic regression analysis.

RESULTS

The overall prevalence of the MS in participants of this study was 147 (18.9%). After multiple adjustments, compared with the highest quartile serum 25- (OH)D level group (19.9-55.9 ng/ml), the odds ratio for MS in the lowest level group (4.2-9.7 ng/ml) was 2.44 [95% confidence interval (CI)=1.32-4.48], in the lower level group (9.8- 14.1 ng/ml) was 2.20 (95% CI=1.24-3.90), and in the intermediate level group (14.3-19.8 ng/ml) was 1.81 (95% CI=1.02-3.20). Among the components of MS, the adjusted odds ratios for having an elevated blood pressure, and high triglyceride level in the lowest level group were 1.81 (95% CI, 1.15-2.85), 2.74 (95% CI, 1.64-4.57), respectively.

CONCLUSIONS

We found that a low serum 25-(OH)D level is significantly associated with the presence of MS and some metabolic components, especially the high triglyceride level and blood pressure in post-menopausal women.

Modified Ilizarov technique for the treatment of forearm deformities in multiple cartilaginous exostoses: case series and literature review

The aim of this study is to evaluate the results of gradual ulnar correction and lengthening using the modified Ilizarov technique for the treatment of forearm deformities in patients with multiple cartilaginous exostoses. We retrospectively reviewed 23 forearms in 16 patients. Three different types of operative procedures were performed: (1) corrective osteotomy and gradual lengthening of the ulna, (2) corrective osteotomy of the radius, and (3) excision of exostoses. We evaluated the radiographs; range of motion of the wrist, forearm, and elbow; and functional status using a questionnaire before and after operation. During the clinical interview, post-operative functional status was significantly improved than pre-operative functional status, 12 patients stated that they had no difficulty in performing daily activities, 11 patients stated that they had no pain, and 11 patients stated that the post-operative appearance of the operated forearm was satisfactory. At time of final follow-up, the mean range of motion of the wrist in ulnar/radial deviation, forearm pronation/supination was significantly improved. Also, the radiographic parameters including radial articular angle, carpal slip, radial bowing, and ulnar variance were significantly improved at time of final follow-up. In conclusion, we achieved successful clinical and radiological outcomes in our patients with forearm deformities after treatment with the modified Ilizarov method. However, there could be a recurrence of ulnar shortening and deformity during growth periods in skeletally immature patients.

Platelet count alterations associated with escitalopram, venlafaxine and bupropion in depressive patients

The objective of the present study was to evaluate changes in platelet counts on three different kinds of antidepressant. All subjects (n = 131) in their drug-naïve state had been diagnosed with depression. Escitalopram (n = 42), venlafaxine (n = 50) and bupropion (n = 39) were prescribed, and platelet count was measured before and after 1 month of treatment and compared. Decrease in platelet count on escitalopram was significant, while the others were not. These findings suggest that escitalopram may be associated with decreased platelet count, and bupropion is less likely to exert an influence on platelet count.

Growth disturbance after lengthening of the lower limb and quantitative assessment of physeal closure in skeletally immature patients with achondroplasia

This study evaluated the effect of limb lengthening on longitudinal growth in patients with achondroplasia. Growth of the lower extremity was assessed retrospectively by serial radiographs in 35 skeletally immature patients with achondroplasia who underwent bilateral limb lengthening (Group 1), and in 12 skeletally immature patients with achondroplasia who did not (Group 2). In Group 1, 23 patients underwent only tibial lengthening (Group 1a) and 12 patients underwent tibial and femoral lengthening sequentially (Group 1b). The mean lengthening in the tibia was 9.2 cm (59.5%) in Group 1a, and 9.0 cm (58.2%) in the tibia and 10.2 cm (54.3%) in the femur in Group 1b. The mean follow-up was 9.3 years (8.6 to 10.3). The final mean total length of lower extremity in Group 1a was 526.6 mm (501.3 to 552.9) at the time of skeletal maturity and 610.1 mm (577.6 to 638.6) in Group 1b, compared with 457.0 mm (411.7 to 502.3) in Group 2. However, the mean actual length, representing the length solely grown from the physis without the length of distraction, showed that there was a significant disturbance of growth after limb lengthening. In Group 1a, a mean decrease of 22.4 mm (21.3 to 23.1) (4.9%) was observed in the actual limb length when compared with Group 2, and a greater mean decrease of 38.9 mm (37.2 to 40.8) (8.5%) was observed in Group 1b when compared with Group 2 at skeletal maturity. In Group 1, the mean actual limb length was 16.5 mm (15.8 to 17.2) (3.6%) shorter in Group 1b when compared with Group 1a at the time of skeletal maturity. Premature physeal closure was seen mostly in the proximal tibia and the distal femur with relative preservation of proximal femur and distal tibia. We suggest that significant disturbance of growth can occur after extensive limb lengthening in patients with achondroplasia, and therefore, this should be included in pre-operative counselling of these patients and their parents.

Femoral lengthening in achondroplasia: magnitude of lengthening in relation to patterns of callus, stiffness of adjacent joints and fracture

Extensive limb lengthening may be indicated in achondroplastic patients who wish to achieve a height within the normal range for their population. However, increasing the magnitude of lengthening is associated with further complications particularly adjacent joint stiffness and fractures. We studied the relationship between the magnitude of femoral lengthening and callus pattern, adjacent joint stiffness and fracture of the regenerate bone in 40 femoral lengthenings in 20 achondroplastic patients. They were divided into two groups; group A had lengthening of less than 50% and group B of more than 50% of their initial femoral length. The patterns of radiological callus formation were classified according to shape, type and features. The incidence of callus features, knee stiffness and regenerate bone fracture were analysed in the two groups. Group B was associated with an increased incidence of concave, lateral and central callus shapes, adjacent joint and stiffness and fracture. Statistically, the incidence of stiffness in adjacent joints and regenerate bone fracture was significantly associated with the magnitude of lengthening. We suggest that careful radiological assessment of the patterns of callus formation is a useful method for the evaluation and monitoring of regenerate bone.

Metabolic syndrome and quality of life (QOL) using generalised and obesity-specific QOL scales

OBJECTIVES

We investigated the association between metabolic syndrome (MS) and health-related quality of life (HRQOL) assessed using generalised and obesity-specific QOL instruments.

METHODS

We recruited 456 outpatients [age: 19-81 years, body mass index (BMI): 16.3-36.7 kg/m2] in the primary care division from 12 general hospitals in Korea. HRQOL was measured using EuroQol comprising the health states descriptive system (EQ-5D) and visual analogue scale (EQ-VAS) as a general instrument. The Korean Obesity-related QOL scale (KOQOL) composed of six domains was used as a disease-specific QOL instrument. MS was defined on the basis of International Diabetes Federation (IDF) criteria with Korean-specific waist circumference cutoffs (men: 90 cm, women: 85 cm).

RESULTS

Subjects with MS displayed significantly higher impairment of EQ-5D and KOQOL. Binary logistic regression analysis of MS patients with controls for age, gender, smoking, alcohol, exercise, education, income, marital status and medication history disclosed odds ratio (OR) values of 2.13 (1.33-3.41) for impaired total KOQOL, 2.07 (1.31-3.27) for impaired physical health, 1.63 (1.03-2.60) for impaired work-related health, 2.42 (1.45-4.04) for impaired routine life, 2.08 (1.27-3.40) for impaired sexual life and 2.56 (1.59-4.11) for diet distress. Among the EQ-5D dimensions, only pain/discomfort displayed a significantly increased OR of 1.60 (1.01-2.56) in MS group.

CONCLUSIONS

Subjects with MS displayed a significantly impaired HRQOL compared with those without MS. MS and HRQOL were more strongly associated in obesity-specific QOL than in generalised QOL.

A cell culturing system that integrates the cell loading function on a single platform and evaluation of the pulsatile pumping effect on cells

In this paper, we present a novel microfluidic system with pulsatile cell storing, cell-delivering and cell culturing functions on a single PDMS platform. For this purpose, we have integrated two reservoirs, a pulsatile pumping system containing two soft check valves, which were fabricated by in situ photopolymerization, six switch valves, and three cell culture chambers all developed through a simple and rapid fabrication process. The sample volume delivered per stroke was 120 nl and the transported volume was linearly related to the pumping frequency. We have investigated the effect of the pulsatile pneumatic micropumping on the cells during transport. For this purpose, we pumped two types of cell suspensions, one containing human breast adenocarcinoma cells (MCF-7) and the other mesenchymal stem cells (hMSCs) derived from bone marrow. The effect of pulsatile pumping on both cell types was examined by short and long-term culture experiments. Our results showed that the characteristics of both cells were maintained; they were not damaged by the pumping system. Evaluations were carried out by morphological inspection, viability assay and immunophenotyping analysis. The delivered MCF-7 cells and hMSCs spread and proliferated onto the gelatin coated cell culture chamber. This total micro cell culture system can be applied to cell-based high throughput screening and for co-culture of different cells with different volume.

Development of genu varum in achondroplasia: relation to fibular overgrowth

Genu varum in the achondroplastic patient has a complex and multifactorial aetiology. There is little mention in the literature of the role of fibular overgrowth. Using the ratio of fibular to tibial length as a measurement of possible fibular overgrowth, we have related it to the development of genu varum. Full-length standing anteroposterior radiographs of 53 patients with achondroplasia were analysed. There were 30 skeletally-immature and 23 skeletally-mature patients. Regression analysis was performed in order to determine if there was a causal relationship between fibular overgrowth and the various indices of alignment of the lower limb. Analysis showed that the fibular to tibial length ratio had a significant correlation with the medial proximal tibial angle and the mechanical axial deviation in the skeletally-immature group. We conclude that there is a significant relationship between fibular overgrowth and the development of genu varum in the skeletally-immature achondroplastic patient.

Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty

Twenty-two patients with infected total hip arthroplasty were treated with 2-stage arthroplasty, using a cement spacer impregnated with a combination of 3 thermostable antibiotics (vancomycin, gentamicin, and cefotaxime). Initially, implants were removed, and a spacer was inserted. Six to 12 weeks later, the spacer was removed, and the patients underwent reconstruction using cementless components. The patients were followed for an average of 41 months. One patient had a recurrence of infection and was treated with resection arthroplasty. The remaining 21 patients (95%) had no evidence of infection at the final follow-up. We recommend using the combination of these 3 antibiotics in the cement spacer for 2-stage reconstruction in infected hip arthroplasty when the causative organism is not identified in the culture of preoperative aspiration.

Subcapital fractures associated with extensive osteonecrosis of the femoral head

The authors reviewed 10 patients with subcapital fractures associated with extensive osteonecrosis of the femoral head and distinguished these fractures from traumatic femoral neck fractures The mean age of the patients was 52 years (range, 36-68 years). Nine patients were younger than 60 years. Eight patients had risk factors for osteonecrosis. Necrosis was extensive and involved nearly the whole femoral head. Fracture occurred at the junction between a necrotic bone and reparative bone and extended downward through the reparative interface to the healthy inferior cortex of the femoral neck. Patients experienced hip pain that was aggravated gradually during a period of 1 to 24 weeks before diagnosis of the fracture. In all patients, the opposite femoral head was involved with osteonecrosis. In two femoral heads, slight collapse or subchondral fracture (crescent sign) also was observed. No patient had a history of precipitating trauma. In patients younger than 60 years with a subcapital fracture, fracture associated with extensive osteonecrosis of the femoral head should be suspected when a history of trauma is not obvious, when the opposite hip shows findings of osteonecrosis, and when the patient has a risk factor of osteonecrosis. In these fractures, osteosynthesis rarely should be considered because of the high failure rate caused by additional progression of extensive osteonecrosis and the probability of nonunion.

Trochanteric rotational osteotomy for osteonecrosis of the femoral head

The rate of success of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head may be improved if patients are preselected using MRI. We have used three criteria for selection for osteotomy (i) minor collapse of the infarcted area, loss of congruity or the crescent sign, without narrowing of the joint space or acetabular involvement (ii) patients younger than 55 years and with a painful hip (iii) patients with an intact area constituting an arc of more than 120 degrees between the central vertical line of the femoral head and the posterior or anterior margin of the necrotic portion as seen on a midsagittal MRI. Seventeen patients were selected, with a follow-up of more than 42 months. A bone scan four weeks after operation showed adequate perfusion of the proximal segment in all hips. The hip score of Merle d'Aubigné et al improved from 13.5 points before operation to 17.2 points at the latest follow-up. Further collapse of the femoral head did not occur. The use of MRI instead of plain radiographs for the selection of patients has improved the success rate of transtrochanteric rotational osteotomy.

Purification and characterization of iron superoxide dismutase and copper-zinc superoxide dismutase from Acanthamoeba castellanii

Two superoxide dismutases (SOD I and SOD II) were purified from Acanthamoeba castellanii and characterized for several biochemical properties. Analysis of the primary structure and inhibition studies revealed that SOD I is iron SOD (Fe-SOD), with a molecular mass of 50 kDa, and SOD II is copper-zinc SOD (Cu,Zn-SOD), with a molecular mass of 38 kDa. Both enzymes have a homodimeric structure consisting of 2 identical subunits, each with a molecular mass of 26 and 19 kDa for SOD I and SOD II, respectively. The isoelectric points of SOD I and SOD II were 6.4 and 3.5, respectively, and there were no isoenzyme forms detected. Both enzymes show a broad optimal pH of 7.0-11.0. Because no differences were observed in the apparent molecular weight of SOD I after addition of the reducing agent 2-mercaptoethanol, the subunits do not appear to be linked covalently by disulfide bonds. However, the subunits of SOD II were covalently linked by intra- and interdisulfide bonds. Western blot analyses showed that the 2 enzymes have different antigenicity. Both enzymes occur as cytoplasmic and detergent-extractable fractions. These enzymes may be potential virulence factors of A. castellanii by acting both as antioxidants and antiinflammatory agents. These enzymes may be attractive targets for chemotherapy and immunodiagnosis of acanthamoebiasis.

Classification of metaphyseal change with magnetic resonance imaging in Legg-Calvé-Perthes disease

Seventy-eight patients (85 affected hips and 71 unaffected hips) with Legg-Calvé-Perthes disease were included in this study to evaluate the metaphyseal change in radiographs and magnetic resonance imaging (MRI) and to define the type of the metaphyseal cyst according to presence or absence of the epiphyseal involvement. The content of the metaphyseal cyst was evaluated by using T1,T2, proton, and gadolinium-enhanced T1-weighted MRI scans. Among 85 hips, there were no changes in 32 hips, marrow edema in 13 hips, false cyst with epiphyseal involvement in 28 hips, and true cyst without epiphyseal involvement in 12 hips. Granulation tissue was found in the false cysts and water-rich fibrotic tissue was found in the true cysts based on the MRI scans. The metaphyseal change in MRI scans was shown in 71% of groups 3 and 4 and in 35% of groups 1 and 2 according to the Catterall classification, and 52% of group A, 56% of group B, and 86% of group C according to the Herring classification. Of the 30 hips at the avascular stage, 33% showed metaphyseal cyst in MRI scans. Of the 53 hips at the fragmentation stage, 60% showed the metaphyseal cyst.

Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images

PURPOSE

To determine whether the marrow edema around focal osteonecrosis on magnetic resonance (MR) images is associated with clinical symptoms.

MATERIALS AND METHODS

Thirty-three patients with 37 hips showing early stage osteonecrosis of the femoral head were followed up at 3-month intervals with clinical evaluation, conventional radiography, and serial MR imaging.

RESULTS

Seven (50%) of 14 symptomatic hips showed marrow edema around focal osteonecrosis on initial MR images, whereas only one (4%) of 23 asymptomatic hips showed edema (P < .01). Six (86%) of seven hips that were moderately to severely painful were associated with surrounding marrow edema. All eight hips showing osteonecrosis with marrow edema at the initial MR examination had joint effusion and exhibited intense radionuclide uptake in the proximal femur, which corresponded to the extent of edema on MR images. In all eight hips, the marrow edema resolved on follow-up MR images, and the pain subsided with the resolution of edema.

CONCLUSION

The results of this study suggest that the combination of marrow edema of the proximal femur and focal osteonecrosis of the femoral head are strongly associated with hip pain in early stage osteonecrosis, even prior to collapse. Pain improvement usually parallels the resolution of edema.

Studies on the sedative and hypnotic effects of oleamide in mice

The hypnotic and sedative effects of oleamide (CAS 301-02-0) were studied in mice. Intraperitoneal injection of oleamide showed a time-related inhibition of the locomotor activity with the maximum effect appearing 30 min after drug administration. Oleamide, at the dose range of 43.7-700 mg/kg, dose-dependently inhibited the locomotor activity in mice. Oleamide could promote the hypnotic action induced by sodium pentobarbital. The interaction studies showed that oleamide potentiated the inhibitory effect of diazepam (CAS 439-14-5) and antagonized the stimulatory effect of ethanol, methamphetamine, and caffeine, respectively. These results provide further evidence for the hypnotic and sedative effects of oleamide, suggesting a potential therapeutic usefulness of this fatty acid amide.

Identification of a new polymorphism in the 3'-untranslated region of the human serotonin receptor 2C (5-HT2C) gene

We identified a polymorphism (2831T > G) in the 3'-untranslated region of 5-HT2C receptor gene, approximately 100 kb from a previously reported coding sequence polymorphism, 796G > C (C23S). Allele frequencies were 0.90 (T) and 0.10 (G) and cosegregation analysis of the alleles at the two loci demonstrated frequencies of 0.82 (GT), 0.08 (CT), 0.10 (GG), and 0 (CC). The increased informativity gained by analysis of both polymorphisms will prove useful for future studies of this gene in X-linked neuropsychiatric disorders.

Clubfoot analysis with three-dimensional foot models

The purpose of this study was to develop a method of defining, in mathematical terms, the interpositional relationships of the bones of the hindfoot complex in the idiopathic clubfoot and the neurogenic clubfoot. The neurogenic clubfoot and contralateral normal-appearing foot of a stillborn infant with myelomeningocele, and the normal foot of a 10-year-old were sectioned with a cryomicrotome. Magnetic resonance images (MRIs) of the clubfoot and the normal foot of a 3-month-old boy were obtained. Using a computer program, three-dimensional foot models were generated from the digitized cryomicrotome sections and from the MRIs. The central principal axes were determined for the talus and calcaneus. The long central principal axes of the talus and calcaneus were neutrally rotated with reference to the bimalleolar axis in the idiopathic clubfoot while in the neurogenic clubfoot the long central principal axis of the talus was medially rotated 52 degrees and that of the calcaneus 10 degrees. The talocalcaneal angles defined by the long central principal axes in the superior and medial views were 0 degree and 10 degrees, respectively, in the idiopathic clubfoot, and 42 degrees and 56 degrees, respectively, in the neurogenic clubfoot.

Comparison of MRI with subchondral fracture in the evaluation of extent of epiphyseal necrosis in the early stage of Legg-Calvé-Perthes disease

We reviewed 20 patients in the early stage of Legg-Calvé-Perthes disease who showed a subchondral fracture line in radiographs. All 20 patients underwent magnetic resonance imaging (MRI) within 2 months after the first symptoms. Follow-up MRI after treatment was performed in 10 patients. The subchondral fracture line in radiographs and serial T1-weighted image was used to measure the extent of the epiphyseal necrosis volumetrically. These extents in the early stage were compared with those in the late stage for determination of prognostic significance. The intensities of coronal MRIs under the subchondral fracture were not homogeneous. The uninvolved epiphysis also showed nonhomogeneous intensities because the posterior column revealed higher intensity compared with the anterior column. The extent of the subchondral fracture line is more accurate in predicting the amount of eventual necrosis than is the extent of necrosis in MRI, which does not have a consistent correlation.

Tibial bone defects treated by internal bone transport using the Ilizarov method

We reviewed 27 cases of tibial bone defects treated by internal bone transport using the Ilizarov method. The causes of the bone defects were open fractures in 14 segments and infected non-unions in 13. The average length of the defects was 8.3 cm (range, 3-20 cm). There were 21 one-level tibial transports, 3 two-level tibial transports, 1 one-level tibial transport with fibular transport, and 2 fibular transports. At the docking site, 25 segments underwent bone grafting. Eleven of the 25 were Papineau-type open cancellous bone grafts. Acute shortening or docking was performed in 10 segments. Bone union was obtained in every instance. The average time of external fixation was 8 months and the average time to union was 7.1 months. Bone grafting at the docking site is recommended in order to shorten the duration of treatment and to prevent refracture and non-union.

Relationship between lateral subluxation and widening of medial joint space in Legg-Calvé-Perthes disease

Fifty-five patients (61 affected hips and 49 unaffected hips) with Perthes disease were reviewed to evaluate the relationship between widening of medial joint space and lateral subluxation of the femoral head in radiographs. The components of the medial joint space were evaluated by using T1, T2, proton, and Gd-enhanced T1WI magnetic resonance images (MRI). The widened medial joint space in radiographs was filled with overgrown cartilage at the initial stage (27 hips) in MRI, with both overgrown cartilage and widened true medial joint space at the fragmentation stage (23 hips) and widened true medial joint space at the healing stage (11 hips). Between affected hips and unaffected hips, the mean difference of medial joint space in radiographs between hips at the initial stage and at the fragmentation stage was 2 and 4.5 mm, respectively; the mean difference in percentage of lack of coverage of the femoral head between hips at the initial stage and at the fragmentation stage was 3 and 15%, respectively. During the healing stage, widening of the medial joint space decreased or normalized because of ossification of overgrown cartilage despite the existence of lateral subluxation because of coxa magna. We concluded that widening of the medial joint space may be used as an index of lateral subluxation at only the fragmentation stage in Perthes disease.

Age-related marrow conversion in the proximal metaphysis of the femur: evaluation with T1-weighted MR imaging

PURPOSE

To determine the normal chronologic changes in fatty marrow conversion of the proximal femoral metaphysis at magnetic resonance (MR) imaging.

MATERIALS AND METHODS

The "marrow conversion index," (signal intensity of the proximal femoral metaphysis divided by signal intensity of the greater trochanter) x 100, was measured in 182 hips of 91 patients who had no evidence of osteonecrosis or diseases involving bone marrow, no history of steroid treatment, and no other risk factors for osteonecrosis. The results were evaluated according to patient age and sex.

RESULTS

The index showed a progressive linear increase with age regardless of sex. The index was 65.4% +/- 5.6 (standard deviation) in patients aged 15-19 years and increased monotonously with age to 87.5% +/- 7.0 in patients aged 60-79 years. Simple linear regression of the index according to age group showed that the marrow conversion index is roughly equal to 63 + 4 x Z (p < .001), where Z is 1.5 for patients aged 15-19 years, 2.0 for patients aged 20-29 years, 3.0 for patients aged 30-39 years, 4.0 for patients aged 40-49 years, 5.0 for patients aged 50-59 years, and 6.0 for patients aged 60-79 years.

CONCLUSION

There is a linear association of marrow conversion index and age. The estimating equation may provide baseline information for the marrow conversion index.

Femoral varus derotation osteotomy with or without acetabuloplasty for unstable hips in cerebral palsy

We reviewed 39 children with cerebral palsy who had surgery for hip subluxation or dislocation. Of 55 treated hips, 31 had a varus derotation osteotomy alone, and 24 had a combination of varus derotation osteotomy and an acetabular procedure. There was no significant difference in the ages of the two groups. There was no difference in the preoperative acetabular indices of the two groups, but the average percentage of preoperative uncoverage of the femoral head was 56% in the group with varus derotation osteotomy and 63% in the group with combined varus derotation osteotomy with an acetabular procedure. The incidence of resubluxation or redislocation (24%) after varus derotation osteotomy alone was higher than that after varus derotation osteotomy with an acetabular procedure (13%). The incidence of postoperative hip instability was higher in the patients who had preoperative uncoverage of the femoral head ranging from 70 to 100%. This was in comparison with the patients who had preoperative uncoverage of the femoral head ranging from 30 to 70%. These results suggest that a combination of varus derotation osteotomy and an acetabular procedure decreases the incidence of resubluxation or redislocation, and that unstable hips with > 70% uncoverage of the femoral head should undergo the combined procedure.

Treatment of antecubital pterygium in the nail-patella syndrome

Antecubital pterygium is rare in the nail-patella syndrome but common in the multiple pterygium syndrome and aplasia of the trochlea. It is known that there is the rebound phenomenon after treatment of congenital joint contracture. We describe the poor functional results due to rapid recurrence of the flexion contracture treated with the Ilizarov method for an antecubital pterygium in the nail-patella syndrome.

Antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis

Fifty-four patients with chronic osteomyelitis of the long bones were treated at Gyeong-Sang National University Hospital between 1985 and 1993 using the cement bead technique. We studied the results of thirty-one patients who were followed up for 3 years or more. The average duration of follow-up was 4 years and 2 months (range: 3 to 7 years). All of the patients were treated by a two-stage operation; primary saucerization with implantation of antibiotic-impregnated polymethylmethacrylate beads and secondary bone grafts. The most recent follow-up examinations and analyses revealed that 17 patients (55%) were completely free of infection. Ten patients (32%) required repeated procedures of curettage and/or bone grafting. Amputations were performed on 4 patients.

Supracondylar osteotomy with Ilizarov fixation for elbow deformities in adults

Stable fixation after a corrective supracondylar osteotomy in adults is difficult because of the irregularity of the area of bony contact, displacement of the fragments, the predominance of cortical bone, and the need for early mobilisation. We have used the Ilizarov apparatus for fixation in 15 patients who were treated by complex osteotomies with displacement of fragments for cubitus varus or valgus. Most patients with cubitus varus required medial displacement with rotation of the distal fragment. Those with cubitus valgus required lateral shift of the distal fragment to reduce the medial prominence of the elbow that would otherwise result. All osteotomies united within the expected time without loss of correction, despite early mobilisation. Complications related to the fixation were few and had resolved at the long-term follow-up.

Gait electromyography in children with myelomeningocele at the sacral level

OBJECTIVE

Patients with sacral level myelomeningocele can be expected to maintain a high level of ambulatory status long into adulthood. Gait deterioration and knee pain reported in this population may be attributed to compensatory movements and increased recruitment of less affected muscle groups to achieve this desired level of ambulation. The objective of this study was to analyze the effect of the solid ankle-foot-orthoses (AFOs) on the muscular activity of selected muscles during walking.

DESIGN

Cohort/outcome.

SETTING

Laboratory.

PATIENTS

Twenty four patients with sacral level myelomeningocele between 4 to 17 years of age.

INTERVENTION

Electromyographic activity of selected muscle groups were studied during barefoot walking and walking with solid AFOs at a self-selected walking velocity.

MAIN OUTCOME MEASURES

Timing of electromyographic activity and sagittal plane knee kinematics. Comparison to normal electromyographic patterns and changes between barefoot and AFO walking conditions.

RESULTS

With the AFOs there was significantly less prolonged stance phase quadriceps activity compared with barefoot walking, although greater than normal activity persisted. There was no change between conditions for the other monitored muscle groups. All muscles elicited greater duration of activity over the course of the gait cycle.

CONCLUSIONS

Our results show that solid AFOs improve the prolonged knee extensor activity evident for barefoot walking. This is clinically relevant to the gait deterioration and knee pain sometimes seen in this patient population. We espouse early and persistent orthotic intervention to reduce compensatory muscular overactivity and maintain gait quality.

Freeman-Sheldon syndrome (whistling face syndrome) and cranio-vertebral junction malformation producing dysphagia and weight loss

The whistling face syndrome has been reported, with complications of the respiratory system and feeding problems due to microstomia, since 1938. Dysphagia, however, has not previously been reported as a complication of whistling face syndrome. We report a 13-year-old with the whistling face syndrome and dysphagia of late onset who has the typical whistling face, scoliosis and multiple joint contractures. Dysphagia occurred as a result of compression at the cervicomedullary junction by a cranio-vertebral junction malformation and impingement by the tip of the odontoid process. This child had undergone multiple surgical procedures for cleft palate, clubfeet, contractures of the hip and knee and scoliosis. Halo traction and posterior occipital-cervical decompression and fusion successfully treated the dysphagia.

Preventing collapse in early osteonecrosis of the femoral head. A randomised clinical trial of core decompression

We performed a randomised trial on 37 hips (33 patients) with early-stage osteonecrosis (ON). After the initial clinical evaluation, including plain radiography and MRI, 18 hips were randomly assigned to a core-decompression group and 19 to a conservatively-treated group. All the patients were regularly followed up by clinical evaluation, plain radiography and MRI at intervals of three months. Hip pain was relieved in nine out of ten initially symptomatic hips in the core-decompression group but persisted in three out of four initially painful hips in the conservatively-treated group at the second assessment (p < 0.05). At a minimum follow-up of 24 months, 14 of the 18 core-decompressed hips (78%) and 15 of the 19 non-operated hips (79%) developed collapse of the femoral head. By survival analysis, there was no significant difference in the time to collapse between the two groups (log-rank test p = 0.79). Core decompression may be effective tin symptomatic relief, but is of no greater value than conservative management in preventing collapse in early osteonecrosis of the femoral head.

Angiography, scintigraphy, intraosseous pressure, and histologic findings in high-risk osteonecrotic femoral heads with negative magnetic resonance images

One hundred twenty-six hips of 68 patients who were suspected of having osteonecrosis or being at risk for osteonecrosis were studied with magnetic resonance (MR) imaging. Abnormal patterns on MR imaging characteristic of osteonecrosis were observed in 98 hips. The remaining 28 hips (22 patients) with negative MR images underwent superselective angiography of the medial femoral circumflex artery. Angiography showed interruption of the superior retinacular arteries in 13 hips (12 patients), including 6 of 7 symptomatic hips. Bone scans were performed on 8 of 13 hips angiographically positive for osteonecrosis. Decrease of radionuclide uptake (cold lesions) was observed in all 8 of these femoral heads. Thirteen femoral heads with interruption of superior retinacular arteries underwent intraosseous pressure measurement and core biopsy. Intraosseous pressure was elevated in 11 hips. The results of histologic study showed evidence of early necrosis in 10 femoral heads. This study indicates that there are a considerable number of femoral heads at high risk, even when they have negative MR images. They do, however, show positive findings on angiography, scintigraphy (cold lesions), intraosseous pressure measurement, and histologic study.