Talus Avascular Necrosis as a Rare Complication of Cushing's Disease: A Case Report

Avascular necrosis (AVN), also called osteonecrosis, stems from blood supply interruption to the bone and is often idiopathic. It has risk factors like trauma, alcohol, and corticosteroids. AVN in the talus (AVNT) is less common than in the femoral head. Most cases of talar osteonecrosis are associated with trauma, while a smaller proportion is linked to systemic conditions such as sickle cell disease or prolonged prednisone use. Glucocorticoids are a key nontraumatic cause. We report a middle-aged woman with Cushing's syndrome symptoms, such as hypertension and moon face, since her youth. A few years ago, she experienced pain and swelling in her ankle, which was diagnosed as atraumatic AVNT and treated with hindfoot fusion. Years later, she was diagnosed with Cushing's disease caused by an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in laboratory tests and imaging, which was resected in 2020. She experienced significant weight loss, and her Cushing's syndrome symptoms were relieved after tumor resection. Mechanisms behind AVN in hypercortisolism involve fat cell hypertrophy, fat embolization, osteocyte apoptosis, and glucocorticoid-induced hypertension. Traditional X-rays may miss early AVN changes; MRI is preferred for early detection. Although there are some cases of femoral AVN caused by endogenous hypercortisolism in the literature, as far as we know, this is the first case of AVNT due to Cushing's disease. AVNT treatment includes conservative approaches, hindfoot fusion, and core decompression. Cushing's disease is a rare cause of AVNT, and a multidisciplinary approach aids in the rapid diagnosis of elusive symptoms.

A New Horizon in Hip Health: Using an Innovative Variable Loop Curette for Core Decompression and Bone Marrow Aspirate Concentrate in the Management of Pre-collapse Avascular Necrosis of the Hip

Avascular necrosis (AVN) of the femoral head, or osteonecrosis (ON), is a debilitating condition characterized by disrupted blood supply to the hip joint, leading to subchondral bone necrosis, joint collapse, and arthritis. Emerging evidence suggests that the long-term use of corticosteroids, particularly in the context of COVID-19 treatment, may contribute to AVN development. This case report presents a male in his 50s with bilateral hip pain and a history of corticosteroid use. The patient underwent core decompression (CD) with a bone marrow aspirate concentrate (BMAC) infusion using the innovative curette technique. Postoperatively, he followed a structured rehabilitation protocol and experienced significant pain relief and improved function. Reviewing existing literature, CD with BMAC using innovative curettes emerges as a promising approach for pre-collapse AVN management, preserving hip function, and delaying the necessity for total hip arthroplasty (THA). This case highlights the potential benefits of this technique in early-stage AVN, emphasizing its role in improving functional outcomes and limiting disease progression.

Freiberg's Disease Involving First Metatarsal Bone Bilaterally in an African Male Patient: A Case Report

Freiberg's disease is a rare disorder affecting the distal metatarsal bones. With no quantitative estimate of its prevalence, the exact pathophysiology of Freiberg's disease is not clearly recognized. However, micro-trauma, repetitive injury, and vascular insufficiency have been implicated the most as predisposing factors for the condition. Freiberg's disease typically presents in adolescent females with higher body mass index (BMI), involving the second and third metatarsal bones with an eventually destructive inflammatory process comprising swelling, hotness, tenderness, and marked restriction of movement. We report a greatly unique and highly atypical presentation of Freiberg's disease in a middle-aged African male with bilateral and symmetrical involvement of the first metatarsal bones, a pattern of involvement that is considered highly anecdotal and atypical rarity of presentation of Freiberg's disease.

COVID-19-Related Bilateral Avascular Necrosis of the Femoral Head

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.

Trends in the Use of Total Hip Arthroplasty in the Pediatric Population: A Review of the Literature

Current literature shows that the utilization of total hip arthroplasty (THA) to address pediatric hip pathology has seen a significant rise worldwide in recent decades. However, performing THA in pediatric patients presents unique challenges due to their increased activity levels, varying skeletal maturity, and diverse medical conditions. These challenges have relegated THA to a secondary option for young patients. Nonetheless, despite these difficulties, recent studies have demonstrated a growing prevalence of THA in pediatrics. Consequently, there is an urgent need for a comprehensive review of the existing literature on this topic. In this study, we examined large database and single-institution studies involving pediatric patients aged 21 years and under who underwent THA. The primary indications for THA in this population were osteoarthritis, osteonecrosis, and inflammatory arthritis. To ensure informed decision-making for pediatric patients, it is crucial to gather consolidated information on trends and outcomes related to THA indications. This review aims to provide insights into these trends and facilitate better decision-making for the treatment of pediatric patients.

Osteonecrosis in Gaucher disease in the era of multiple therapies: Biomarker set for risk stratification from a tertiary referral center

Background

A salutary effect of treatments for Gaucher disease (GD) has been a reduction in the incidence of avascular osteonecrosis (AVN). However, there are reports of AVN in patients receiving enzyme replacement therapy (ERT) , and it is not known whether it is related to individual treatments, GBA genotypes, phenotypes, biomarkers of residual disease activity, or anti-drug antibodies. Prompted by development of AVN in several patients receiving ERT, we aimed to delineate the determinants of AVN in patients receiving ERT or eliglustat substrate reduction therapy (SRT) during 20 years in a tertiary referral center.

Methods

Longitudinal follow-ups of 155 GD patients between 2001 and 2021 were analyzed for episodes of AVN on therapy, type of therapy, GBA1 genotype, spleen status, biomarkers, and other disease indicators. We applied mixed-effects logistic model to delineate the independent correlates of AVN while receiving treatment.

Results

The patients received cumulative 1382 years of treatment. There were 16 episodes of AVN in 14 patients, with two episodes, each occurring in two patients. Heteroallelic p.Asn409Ser GD1 patients were 10 times (95% CI, 1.5-67.2) more likely than p.Asn409Ser homozygous patients to develop osteonecrosis during treatment. History of AVN prior to treatment initiation was associated with 4.8-fold increased risk of AVN on treatment (95% CI, 1.5-15.2). The risk of AVN among patients receiving velaglucerase ERT was 4.68 times higher compared to patients receiving imiglucerase ERT (95% CI, 1.67-13). No patient receiving eliglustat SRT suffered AVN. There was a significant correlation between GlcSph levels and AVN. Together, these biomarkers reliably predicted risk of AVN during therapy (ROC AUC 0.894, p<0.001).

Conclusions

There is a low, but significant risk of AVN in GD in the era of ERT/SRT. We found that increased risk of AVN was related to GBA genotype, history of AVN prior to treatment initiation, residual serum GlcSph level, and the type of ERT. No patient receiving SRT developed AVN. These findings exemplify a new approach to biomarker applications in a rare inborn error of metabolism to evaluate clinical outcomes in comprehensively followed patients and will aid identification of GD patients at higher risk of AVN who will benefit from closer monitoring and treatment optimization.

Funding

LSD Training Fellowship from Sanofi to MB.

Does Diabetes Mellitus Increase the Risk of Avascular Osteonecrosis? A Systematic Review and Meta-Analysis

Avascular osteonecrosis (AVN) is caused by the disrupted blood supply to the bone. Most AVN cases occur in the femoral head, but other sites might be affected as well, including the jaw or distal bones of the extremities. Previous studies suggested that diabetes could increase the risk of AVN of the jaw, but the relationship between diabetes and AVN in other bone sites is unclear. This systematic review and meta-analysis aimed to summarize the evidence from studies that had reported on the occurrence of AVN in sites other than the jaw, depending on the diagnosis of diabetes. Overall, we included 6 observational studies carried out in different populations: primary or secondary AVN of the femoral head, Takayasu arteritis, general population, kidney transplant recipients, systemic lupus erythematosus, and primary brain tumors. A random-effects meta-analysis showed that the risk of AVN in sites other than the jaw was non-significantly increased in patients with diabetes (odds ratio: 1.90, 95% confidence interval: 0.93-3.91). The pooled estimate increased and was significant after the exclusion of one study (2.46, 1.14-5.32). There was a significant heterogeneity (I² = 65%, tau² = 0.48, p = 0.01; prediction interval, 0.21-16.84). There was no significant publication bias (p = 0.432). In conclusion, diabetes could increase the risk of AVN in sites other than the jaw, but the available evidence is limited. There is a need for large, well-designed, population-based studies.

Satisfactory Outcomes of All-Poly Fixed Bearing Unicompartmental Knee Arthroplasty for Avascular Osteonecrosis Versus Osteoarthritis: A Comparative Study With 10 to 22 Years of Follow-up

BACKGROUND

While good mid-term results for treating spontaneous knee osteonecrosis (SPONK) with unicompartmental knee arthroplasty (UKA) have been reported, concerns remain about implant survival at long-term. This study aimed to compare outcomes and survivorship of UKA for SPONK vs osteoarthritis at a minimum of 10 years.

METHODS

This case-control study included medial UKA for femoral SPONK operated between 1996 and 2010 with a minimum 10-year follow-up (n = 47). Each case was matched with a medial UKA for osteoarthritis based on body mass index (BMI), gender, and age. Knee Society Score (KSS), complications and radiological (loosening) data were collected at the last follow-up. Kaplan-Meier survivorship analysis was performed using revision implant removal as endpoint.

RESULTS

The mean follow-up was 13.2 years (range 10 to 21 years). Mean age and BMI were 72.9 ± 8.4 years and 25.5 ± 3.6 Kg/m² in SPONK group. At last follow-up, knee and function KSS were 89.5 ± 12 and 79 ± 18 in SPONK group vs 90 ± 15 (P = .85) and 81.7 ± 17 (P = .47) in control group. Complications and radiological results showed no significant differences. The survival rate free from any revision was 85.1% at last follow-up in SPONK group and 93.6% in control group (P = .23). The leading cause for revision was aseptic tibial loosening (57.1%) in SPONK group. The 15-year survival estimate was 83% in SPONK group.

CONCLUSION

Satisfactory clinical outcomes at long-term after UKA for femoral SPONK were observed, similar to those after UKA for osteoarthritis, despite a higher risk of tibial loosening in the SPONK group. No symptomatic femoral loosening leading to a revision was observed.

LEVEL OF EVIDENCE

IV.

Bone Marrow Mesenchymal Stem Cells Overexpressing HIF-1α Prevented the Progression of Glucocorticoid-Induced Avascular Osteonecrosis of Femoral Heads in Mice

Glucocorticoid (GC)-induced avascular osteonecrosis of femoral head (AOFH) is a devastating complication, and no cures are currently available for it. Previous studies have demonstrated that implantation of bone marrow mesenchymal stem cells (BMMSCs) may prevent the progression of pre-collapse AOFH. Based on previous observations, we hypothesized that GCs induce AOFH via the COX-2 (cyclooxygenase-2)-PGE-2 (prostaglandin E2)-HIF-1α (hypoxia-inducible factor-1α) axis, and that modification of BMMSCs may improve the efficacy of their implantation. BMMSCs isolated from wild-type (WT) mice were treated with dexamethasone (Dex) and the results showed that Dex repressed the expression of COX-2. Femoral head samples harvested from both WT and COX-2 knock-out (COX-2^-/-) mice were subjected to micro-computed tomography and histological examinations. Compared with their WT littermates, COX-2^-/- mice had larger trabecular separations, diminished microvasculature, and reduced HIF-1α expression in their femoral heads. In vitro angiogenesis assays with tube formation and fetal metatarsal sprouting demonstrated that Dex repressed angiogenesis and PGE-2 antagonized its effects. An AOFH model was successfully established in C57BL/6J mice. In vitro experiment showed that BMMSCs infected with Lentivirus encoding HIF-1α (Lenti-HIF-1α) resulted in a robust increase in the production of HIF-1α protein. Implantation of BMMSCs overexpressing HIF-1α into femoral heads of AOFH mice significantly reduced osteonecrotic areas and enhanced bone repair, thus largely preserving the structural integrity of femoral heads. Our studies provide strong rationales for early intervention with core decompression and implantation of modified BMMSCs for GC-induced AOFH, which may spare patients from expensive and difficult surgical procedures.

Back Pain Due to Kummell's Disease

Kummell’s disease (KD) is a delayed post-traumatic avascular osteonecrosis of the vertebral body secondary to a vertebral compression fracture that can present with back pain. We discuss the importance of an accurate diagnosis and appropriate management of Kummell’s disease. Additionally, we aim to increase awareness and promote early diagnosis and treatment to prevent serious complications.

A 55-year-old man had been diagnosed with avascular necrosis (AVN) of both hips and had a history of trauma to the left hip ten years ago. Between the initial fall and subsequent presentation, he resumed independent physical activity. At approximately 10 months following his initial injury, he returned to a local emergency department with vague complaints of lower back pain. He was prescribed analgesics for pain and discharged. Subsequently, he experienced a progressive increase in pain and complained of motor deficits of the lower limbs. He presented to our emergency room with acute onset of worsening pain. Magnetic resonance imaging revealed multiple-level compression fractures and a fluid cleft in the L2 intervertebral disc. Surgery was advised, but he did not consent. Therefore, nonsurgical treatment included bed rest, wearing a brace, lumbar traction, analgesics, and medication to prevent osteoporosis.

Prompt, accurate diagnosis of Kummell’s disease is important for timely, appropriate treatment, which can improve quality of life and prevent comorbidities.

Avascular Necrosis of Both Hips From Iatrogenic Cushing 's Syndrome due to Coadministration of Fluticasone and Ritonavir in an HIV-Infected Patient

We report a case of avascular necrosis (AVN), hypercalcemia, and iatrogenic Cushing’s syndrome in an HIV-positive patient taking inhaled (ICS) and nasal corticosteroids fluticasone and ritonavir.

A 45-year-old HIV-infected African-American woman was seen for initial evaluation for multinodular goiter in December 2015. Relevant medications were ritonavir, raltegravir, darunavir, fluticasone propionate HFA, and nasal fluticasone propionate. Physical examination revealed classical cushingoid appearance but laboratory testing showed abnormal adrenocorticotropic hormone (ACTH) stimulation test. A diagnosis of iatrogenic Cushing’s syndrome due to inhibition of fluticasone metabolism from protease inhibitor (PI) therapy with secondary adrenal suppression was made. Fluticasone nasal spray and HFA were discontinued and hydrocortisone replacement dose was initiated. The patient’s Cushing’s related symptoms improved over several months. Follow-up evaluation showed non-parathyroid hormone-mediated hypercalcemia. A detailed laboratory evaluation looking for the etiology for hypercalcemia was unremarkable except for an elevated urine N-telopeptide/creatinine ratio. Meanwhile, the patient developed a new symptom of hip pain. MRI of both hips showed bilateral AVN. Sickle cell screen was negative and a right hip replacement was completed in May 2017.

Since this is the fourth case report of AVN from iatrogenic Cushing’s syndrome in an HIV-infected patient taking a PI and ICS concomitantly, there is more likely a causal relationship and not simply a coincidental finding. Extreme caution should be used when considering any ICS therapy in combination with PIs in HIV-infected patients.

Neuralgia-inducing cavitational osteonecrosis - Fact or myth, the debate persists

Neuralgia-inducing cavitational osteonecrosis (NICO) is a debated condition characterized by cavitary lesions in the maxillary-mandibular region, often missed on conventional radiographs, and the golden standard for diagnostic measures is bone scintigraphy. It may arise secondary to trauma, such as dental extraction and endodontic treatment, and due to a low-grade chronic infection. NICO has been documented as a frequent cause of face pain involving the trigeminal nerve divisions. It may be severe, piercing pain, of short duration or even continuous pain of moderate intensity. It affects females with a greater predilection than males. A lack of awareness of the condition among health professionals is often put into the basket of atypical facial pain. Current studies describe ischemic alveolar bone marrow coagulation disorders as the cause for NICO, which may also be the result of thrombosis with or without hypofibrinolysis, which would obstruct vascular spaces impairing blood flow in the region. Treatment is decided on a case basis, depending on the clinicians’ experience, on previous treatments, on the patient's general status, and more importantly, whether the site is edentulous or dentate. If surgical intervention is chosen, tissue should be sent for pathological examination. Over the years, with the advance of imaging diagnosis processes and the study and detection of genetic changes, one may also include as a cause of NICO the decreased bone marrow blood flow causing bone cavities. All of this was also associated with genetic mutations which would predispose patients to thrombophilia and hypofibrinolysis.

Long-Term Results of Medial Unicompartmental Knee Arthroplasty for Knee Avascular Necrosis

BACKGROUND

Numerous series have documented short and mid-term successes with cemented, metal-backed modern unicompartmental knee arthroplasty (UKA) for avascular osteonecrosis of the knee (AVN). However, data are lacking regarding long-term implant fixation and patient function. The aim of this study is therefore to evaluate the long-term clinical outcome and implant survivorship of patients who underwent UKA for medial knee osteonecrosis (ON).

METHODS

Twenty-nine consecutive UKAs performed by 2 senior surgeons (>50 UKAs a year) in 28 patients (19 women and 9 men with a mean age of 67 years) with medial unicompartmental AVN of the knee between 1989 and 2001 were retrospectively reviewed. AVN was diagnosed using X-ray, magnetic resonance imaging scan, and finally confirmed by postoperative sample analysis. The mean patient body mass index was 27 kg/m². Etiologies were spontaneous/idiopathic AVN in 19 knees (66%) and secondary AVN in 10 knees (33%). The mean follow-up was 21 years (range 15-26).

RESULTS

At 15 years, survivorship of the components free of revision for any cause was 92% (95% confidence interval 87-97). At latest follow-up, 26 years, survivorship of the components free of revision for any reason was 83% (95% confidence interval 74-95). No survivorship difference was found between the patients suffering from spontaneous or secondary ON of the knee (83% vs 90%, P = .6). At latest follow-up, the mean Knee Society Scoring system Knee was 89 points (range 68-100) and 83 (range 66-96) for Knee Society Scoring system Function.

CONCLUSION

In the longest series to date, medial UKA for treatment of AVN was associated with high survival rates and stable clinical improvement. UKA is a durable and efficient option to treat patients with unicompartmental ON of the knee.

LEVEL OF EVIDENCE

IV.

Spontaneous and bilateral necrosis of the femoral head in a young experimental beagle dog

This report describes the pathological characterizations of a rare case of necrosis of the femoral head that was spontaneous, bilateral, avascular and nontraumatic. A 14-month-old beagle dog was presented with pain in the hind limbs. At necropsy, the articular surface in the bilateral femoral head was markedly irregular. There were no gross abnormalities other than in the hip joints. Microscopically, a wide range of trabecular bone necrosis localized in the subchondral area was observed in both femoral heads. In the right femoral head, fibrosis and proliferative vessels were noted in the subchondral area. The articular cartilage was thickened irregularly, but there was no evidence of cartilage necrosis. The bone marrow adjacent to the affected area showed severe depression. In the metaphysis, atrophic bone marrow, but not bone necrosis, was observed. This was a rare case of spontaneous necrosis of the femoral head in an experimental beagle dog.