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Pakhan AA, Phansopkar P, Boob MA. Rehabilitation to Complement Unique Single-Stage Core Decompression and Total Hip Arthroplasty in Bilateral Avascular Necrosis: A Case Report. Cureus 2024; 16:e52914. [PMID: 38406129 PMCID: PMC10893823 DOI: 10.7759/cureus.52914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/24/2024] [Indexed: 02/27/2024] Open
Abstract
Avascular necrosis (AVN), a debilitating condition characterized by bone tissue death due to inadequate blood supply, can severely impact the hip joint, leading to pain, limited mobility, and joint dysfunction. The complex blood supply and mechanical stress on the hip make it particularly vulnerable to AVN. Early detection is challenging as AVN may remain asymptomatic initially, but as it progresses, it results in severe joint degeneration. This case report outlines the management of a 38-year-old male patient with a dermatomyositis history who presented with bilateral hip pain attributed to AVN. Radiological investigations diagnosed grade 2 AVN in the left hip and grade 3 AVN in the right hip. The patient underwent core decompression for the left hip to halt disease progression and total hip arthroplasty (THA) for the right hip to alleviate pain and restore function. A structured three-week rehabilitation program was tailored to each surgical procedure, with pre-and post-treatment assessments revealing notable improvements in pain relief, range of motion (ROM), and muscle strength. This case underscores the importance of early diagnosis, personalized surgical interventions, and comprehensive rehabilitation in managing AVN in dermatomyositis patients. Physiotherapy is vital pre- and post-operatively to enhance physical function, strength, and mobility. Rehabilitation also plays a crucial role in postoperative recovery, early mobilization, and functional restoration. The multifaceted approach employed in this case highlights the need for a comprehensive strategy when managing AVN in dermatomyositis patients, providing valuable insights for similar cases.
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Affiliation(s)
- Arjavi A Pakhan
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Pratik Phansopkar
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Manali A Boob
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Cardín-Pereda A, García-Sánchez D, Terán-Villagrá N, Alfonso-Fernández A, Fakkas M, Pérez-Del Barrio A, Marín-Díez E, Fernández-Lobo V, Sanz-Bellón P, Montes-Figueroa E, Lamprecht Y, Pérez-Campo FM. Diagnostic Reliability of Plain Radiography in Osteonecrosis of the Femoral Head: General Radiological Features Revised. Curr Med Imaging 2023; 20:CMIR-EPUB-134130. [PMID: 37649291 DOI: 10.2174/1573405620666230829150229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/12/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Osteonecrosis of the femoral head (ONFH) is an incapacitating disease that frequently results in the collapse of the femoral head and secondary osteoarthritis. The diagnosis and staging of this pathology, which usually rely on imaging studies, are challenging. Currently, conventional radiography is the basis of the initial diagnostic assessment. In recent decades, however, radiographs have been considered insensitive to early changes in ONFH and thus, a suboptimal diagnostic tool. Paradoxically, the imaging features of radiographs are often profuse, substantial, and characteristic. This study aimed to elucidate the real limitations of this radiologic tool by assessing the diagnostic reliability of the key radiologic features and staging. METHODS This was a retrospective study in which radiographs from 28 idiopathic ONFH confirmed cases who underwent hip arthroplasty were analyzed by eight observers who were asked to identify the presence or absence of ONFH universally reported imaging features in AP hip radiographs. RESULTS Concordance analysis revealed a poor agreement between observers for most of the assessed imaging features. Only the identification of femoral head flattening and osteoarthritis signs exhibited moderate agreement with statistical significance. In contrast, the detection of radiological osteoporosis and the loss of trabeculation showed the lowest reliability, with negative kappa coefficients. CONCLUSION There is a lack of agreement between qualified observers, even for the identification of the most characteristic ONFH radiographic feature. The reliability of plain radiography for the detection of basic radiological elements is even weaker in the early stages of the disease.
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Affiliation(s)
- Adrian Cardín-Pereda
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Cantabria-IDIVAL, 39012, Santander, Spain
| | - Daniel García-Sánchez
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Cantabria-IDIVAL, 39012, Santander, Spain
| | - Nuria Terán-Villagrá
- Servicio de Anatomía Patológica, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, 39008, Santander, Spain
| | - Ana Alfonso-Fernández
- University of Cantabria Servicio de Traumatología y Ortopedia, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria Santander Spain
| | - Michel Fakkas
- Marqués de Valdecilla University Hospital Servicio de Traumatología y Ortopedia, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria Santander Spain
| | - Amaia Pérez-Del Barrio
- Clinica Universidad de Navarra Servicio de Radiología (Sección de Radiología Musculoesquelética), Hospital Universitario de Navarra Pamplona Spain
| | - Elena Marín-Díez
- Marqués de Valdecilla University Hospital Radiology Santander Spain
| | | | | | | | - Yasmina Lamprecht
- Charité - University Medicine Berlin Klinik für Radiologie Berlin Germany
| | - Flor María Pérez-Campo
- University of Cantabria Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Cantabria-IDIVAL Santander Spain
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Inneh A, Martinez K, Elizee J, Ganguli M, Turan A. COVID-19-Related Bilateral Avascular Necrosis of the Femoral Head. Cureus 2023; 15:e44034. [PMID: 37746447 PMCID: PMC10517632 DOI: 10.7759/cureus.44034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
Osteonecrosis is a pathologic process that involves focal bone infarction and death of bone tissue caused by trauma, infections, autoimmune conditions, and chronic steroid use; however, most cases go undiagnosed. The link between bilateral osteonecrosis and coronavirus disease 2019 (COVID-19) infections has not been fully investigated. This is the case of a 42-year-old Caucasian woman who presented to the emergency department for bilateral hip pain, which started three months prior. Initially, the pain was mild; however, her symptoms worsened, causing her to have difficulty ambulating. Co-incidentally she tested positive for COVID-19 10 days after the onset of pain. She denied any lower-extremity numbness, weakness, and loss of bowel or bladder function. X-ray of the hips showed significant sclerosis of bilateral femoral heads and acetabula, indicating avascular necrosis. She was given ketorolac injection intramuscularly for analgesia and remained in stable condition. Upon discharge, she was given a referral to orthopedic surgery for bilateral total hip arthroplasty. Atraumatic osteonecrosis of the femoral head can be caused by multiple etiologies, including exposure to medications, post-transplantation procedures, trauma, and hypercoagulable states. This condition is likely due to poor angiogenesis after an infarct, causing a domino effect of bone demineralization, trabecular thinning, and cortical collapse. A literature search demonstrated prior cases of unilateral femoral head necrosis associated with COVID-19 infection and steroid use. There have been no cases of bilateral osteonecrosis of the femoral head reported without long-term steroid use. Considering the disease severity in both hips and limited steroid use (only five days of prednisone), other common etiologies were sought and were ruled out. In our patient, the only event that was related to her initial onset of hip pain was a COVID-19 infection. We suggest a relationship between COVID-19 infection and avascular necrosis given the rapid progression of the disease. We acknowledge that this presentation of bilateral osteonecrosis is rare and warrants further investigation. More research should be performed to establish a tenable relationship between COVID-19 infection and osteonecrosis, with and without the use of steroids.
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Affiliation(s)
- Adesuwa Inneh
- Urology, Ross University School of Medicine, Pontiac, USA
| | - Kayla Martinez
- Surgery, Ross University School of Medicine, Pontiac, USA
| | - Juleen Elizee
- Pediatrics/Internal Medicine, Ross University School of Medicine, Pontiac, USA
| | - Malika Ganguli
- Internal Medicine, Ross University School of Medicine, Pontiac, USA
| | - Aydin Turan
- Internal Medicine, Trinity Health Oakland Hospital, Pontiac, USA
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DiGiovanna JJ, Randall G, Edelman A, Allawh R, Xiong M, Tamura D, Khan SG, Rizza ERH, Reynolds JC, Paul SM, Hill SC, Kraemer KH. Debilitating hip degeneration in trichothiodystrophy: Association with ERCC2/XPD mutations, osteosclerosis, osteopenia, coxa valga, contractures, and osteonecrosis. Am J Med Genet A 2022; 188:3448-3462. [PMID: 36103153 PMCID: PMC9669218 DOI: 10.1002/ajmg.a.62962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/25/2022] [Accepted: 08/11/2022] [Indexed: 01/31/2023]
Abstract
Trichothiodystrophy (TTD) is a rare, autosomal recessive, multisystem disorder of DNA repair and transcription with developmental delay and abnormalities in brain, eye, skin, nervous, and musculoskeletal systems. We followed a cohort of 37 patients with TTD at the National Institutes of Health (NIH) from 2001 to 2019 with a median age at last observation of 12 years (range 2-36). Some children with TTD developed rapidly debilitating hip degeneration (DHD): a distinctive pattern of hip pain, inability to walk, and avascular necrosis on imaging. Ten (27%) of the 37 patients had DHD at median age 8 years (range 5-12), followed by onset of imaging findings at median age 9 years (range 5-13). All 10 had mutations in the ERCC2/XPD gene. In 7 of the 10 affected patients, DHD rapidly became bilateral. DHD was associated with coxa valga, central osteosclerosis with peripheral osteopenia of the skeleton, and contractures/tightness of the lower limbs. Except for one patient, surgical interventions were generally not effective at preventing DHD. Four patients with DHD died at a median age of 11 years (range 9-15). TTD patients with ERCC2/XPD gene mutations have a high risk of musculoskeletal abnormalities and DHD leading to poor outcomes. Monitoring by history, physical examination, imaging, and by physical medicine and rehabilitation specialists may be warranted.
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Affiliation(s)
- John J. DiGiovanna
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Grant Randall
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
- NIH Medical Research Scholars Program, Bethesda, Maryland, USA
| | - Alexandra Edelman
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Rina Allawh
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Michael Xiong
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Deborah Tamura
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Sikandar G. Khan
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Elizabeth R. H. Rizza
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - James C. Reynolds
- Department of Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Scott M. Paul
- Rehabilitation Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Suvimol C. Hill
- Department of Radiology, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Kenneth H. Kraemer
- DNA Repair Section, Laboratory of Cancer Biology and Genetics, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
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Staines Boone AT, Alcántara-Montiel JC, Sánchez-Sánchez LM, Arce-Cano M, García-Campos J, Lugo Reyes SO. Zoledronate as effective treatment for minimal trauma fractures in a child with STAT3 deficiency and osteonecrosis of the hip. Pediatr Blood Cancer 2016; 63:2054-7. [PMID: 27416072 DOI: 10.1002/pbc.26119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/17/2016] [Accepted: 06/05/2016] [Indexed: 11/08/2022]
Abstract
Signal transducer and activator of transcription 3 (STAT3) deficiency is a primary immunodeficiency characterized by eczema, complicated recurrent infections, elevated serum immunoglobulin E (IgE), osteopenia, and minimal trauma fractures. Zoledronic acid (ZA) is a long-acting bisphosphonate that has been successfully used in children with secondary osteoporosis and osteogenesis imperfecta. We describe the case of a 7-year-old male with STAT3 deficiency and minimal trauma fractures, who also developed osteonecrosis of the hip. He responded well to intravenous ZA every 6 months for 18 months. Three years later, he walks independently and unaided, and has not suffered any other fractures. Although more studies are needed, ZA might help reduce minimal trauma fractures in patients with STAT3 deficiency.
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Affiliation(s)
- Aidé Tamara Staines Boone
- Clinical Immunology Department, Hospital de Especialidades, Mexican Social Security Institute (IMSS), Monterrey, Nuevo León, Mexico.
| | - Julio César Alcántara-Montiel
- Department of Molecular Biomedicine, Center for Research and Advanced Studies (CINVESTAV), National Polytechnic Institute (IPN), Mexico City, Mexico
| | - Luz María Sánchez-Sánchez
- Department of Pediatrics, Hospital de Especialidades, Mexican Social Security Institute (IMSS), Monterrey, Nuevo León, Mexico
| | - Marina Arce-Cano
- Department of Pediatrics, Hospital de Especialidades, Mexican Social Security Institute (IMSS), Monterrey, Nuevo León, Mexico
| | - Jorge García-Campos
- Department of Infectious Diseases, Hospital de Especialidades, Mexican Social Security Institute (IMSS), Monterrey, Nuevo León, Mexico
| | - Saúl Oswaldo Lugo Reyes
- Immunodeficiencies Research Unit, National Institute of Pediatrics (INP), Mexico City, Mexico
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Landgraeber S, Theysohn JM, Classen T, Jäger M, Warwas S, Hohn HP, Kowalczyk W. Advanced core decompression, a new treatment option of avascular necrosis of the femoral head--a first follow-up. J Tissue Eng Regen Med 2012; 7:893-900. [PMID: 22489064 DOI: 10.1002/term.1481] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 10/10/2011] [Accepted: 01/13/2012] [Indexed: 01/21/2023]
Abstract
Aseptic necrosis of the femoral head (AVN) leads to destruction of the affected hip joint, predominantly in younger patients. Advanced core decompression (ACD) is a new technique that may allow better removal of the necrotic tissue by using a new percutaneous expandable reamer. A further modification is the refilling of the drill hole and the defect with an injectable, hard-setting, composite calcium sulphate (CaSO₄)-calcium phosphate (CaPO₄) bone graft substitute. Compression tests were performed on seven pairs of femoral cadaver bones. One femur of each pair was treated with ACD, while the opposite side remained untreated. Clinically, the postoperative outcome of 27 hips in 23 patients was performed by physical examination 6 weeks after ACD and at average follow-up of 9.69 months, and compared with the preoperative results. MRI was used to assess the removal of the necrotic tissue, any possible progression of AVN and evaluation of collapse. In the biomechanical analysis, the applied maximum compression force that caused the fracture did not significantly differ from the untreated opposite side. The overall results of postoperative physical examinations were significantly better than preoperatively. Five hips (18.5%) were converted to a total hip replacement. The follow-up MRIs of the other patients showed no progression of the necrotic area. The first follow-up results of ACD have been encouraging for the early stages of aseptic necrosis of the femoral head. In our opinion, an assured advantage is the high stability of the femoral neck after ACD, which allows quick rehabilitation.
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