Hip-Spine Syndrome: A Focus on the Pelvic Incidence in Hip Disorders

Since Offierski and MacNab reported a close association between the hip and spine as hip-spine syndrome in 1983, many studies on spinal alignment in hip disorders have been conducted. Notably, the pelvic incidence angle (PI) is the most important parameter and is determined by the anatomical variations in the sacroiliac joint and hip. Studies on the association of the PI with hip disorders can help in understanding the pathophysiology of hip-spine syndrome. A PI increase has been observed during the evolution of bipedal locomotion in humans and in the acquisition of gait during child development. Although the PI is a fixed parameter that is stable and unaffected by posture from adulthood onwards, it has become clear that it increases in the standing position in older people. While it may be associated with a greater risk of developing or progressing to spinal disorders, the association between the PI and hip disorders remains controversial because of the multifactorial nature of hip osteoarthritis (HOA) and the wide range of PIs in HOA (18-96°), making the interpretation of results difficult. However, several hip disorders (i.e., femoroacetabular impingement and rapid destructive coxarthrosis) have been shown to be associated with the PI. Further investigation on this topic is, therefore, warranted.

Complications of primary total hip arthroplasty in human immunodeficiency virus-positive patients with femoral head osteonecrosis

BACKGROUND

Femoral head osteonecrosis (FHON) is a well-recognised complication in patients with human immunodeficiency virus (HIV) infection. Total hip arthroplasty (THA) is a reliable solution to FHON and has provided functional improvement and pain relief in these patients. Higher complication rates, in particular infections, have been reported in the series of THAs done in the HIV-positive patients. The purpose of this study was to evaluate the complication rate of THA for FHON in HIV-positive patients managed with the highly active antiretroviral therapy (HAART) protocols.

METHODS

A retrospective review was performed of HIV-positive patients with FHON who underwent THAs over a 10-year period at a single institution.

RESULTS

A total of 56 THAs (44 patients) met the inclusion criteria. The mean age at the time of THAs was 47 (range 34-60) years. Of the 44 patients, 39 (88.6%) were males. The mean follow-up was 6.6 (range 2.0-11.3) years. The overall complication rate was 12.5%, with 2 (3.6%) cases of deep periprosthetic infections.

CONCLUSIONS

HIV-positive patients with FHON undergoing THAs do have a considerable complication rate (12.5%). The deep periprosthetic infection rate (3.6%) in these patients, however, has decreased with contemporary disease modification protocols.

Combination of hyperbaric oxygen and core decompression therapies improve outcomes in the treatment of hip osteonecrosis

INTRODUCTION

To investigate whether combined treatment of hyperbaric oxygen (HBO) and core decompression (CD) result with better outcomes and have an additional influence on health quality scores when compared with HBO alone.

METHODS

63 consecutive patients' 80 hips (43 male, 20 female, 17 bilateral), diagnosed with Stage II Osteonecrosis of the femoral head were included in our study. The mean age at presentation in the HBO and CD + HBO groups were 39.9 years and 39.2 years, respectively. The mean follow-up was 39.8 months (24-56 months) for HBO group and 43.1 months (24-58 months) for the CD + HBO group. Standard radiographs and MRI were performed initially and during controls. Clinical outcomes were assessed using the modified Harris Hip Score (HHS), the visual analogue score (VAS) and SF-36 life quality score.

RESULTS

52 hips (65%) were Ficat Stage IIa and 28 hips (35%) were IIb. Totally, 46 hips (30 hips IIa, 16 hips IIb) were in HBO alone group and 34 hips (22 hips IIa, 12 hips IIb) were in CD + HBO group. Both VAS and HHSs were improved in each group after treatment (p < 0.001). When both groups were compared, this improvement was more distinct and evident in CD + HBO combination group than HBO alone group (p < 0.001). The physical function and pain components of SF-36 survey were found to be different in between two groups (p < 0.005).

DISCUSSION

HBO treatment decreases pain, increases functional scores for Ficat Stage II patients. Addition of HBO treatment to decompression of the femoral head improves the results better than HBO alone. In particular, reduction of pain is more prevalent for Stage IIa patients than IIb with combination of HBO and CD therapies.

Integrative analyses of genes about venous thromboembolism: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

In recent years, many studies have found possible links between gene polymorphisms and venous thromboembolism (VTE). By identifying genetic risk factors before facing environmental risk factors such as surgical interventions and COVID-19 vaccination, we could rapidly respond to the risk of VTE. The aim of this study was to perform an umbrella review of genetic variants related to VTE. Integrative gene analysis of VTE was performed to identify critical genetic variations.

METHODS

This study conducted an umbrella review of systematic reviews and meta-analyses. All included studies were selected from the PubMed/MEDLINE database. To select eligible studies, the following variables were extracted: first author name; effect size of each study genetic variant; year of publication; the number of studies included in each article; ethnicity, sample size, P values, and heterogeneity estimates. To assess cumulative evidence in genetic epidemiology about effects of gene polymorphisms on VTE, Human Genome Epidemiology Network's Venice criteria were used. Methodological quality assessment was conducted with JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.

RESULTS

Genes provided in the present study with genetic variants associated with VTE were FVL (G1691A), Prothrombin (G20210A), MTHFR (C677T, A1298C), PAI-1 (4G/5G), factor VII activating protease (1601G > A), and endothelial protein C receptor (g.6936A_G, c.4600A_G). Among them, variants in FVL, Prothrombin, MTHFR, and PAI-1 showed high significance. Particularly, variants in Prothrombin (G20210A), MTHFR (C677T), and PAI-1 (4G/5G) had more than 2 types of model significance.

CONCLUSION

The present study performed a systematic review of genetic variants associated with VTE. Our results could lead to a more comprehensive understanding of VTE etiology. These results could give a strategy of prediagnosis about evaluating individual risks of VTE who might be exposed to environmental risk factors.

Postacute sequelae of SARS-CoV-2 infection. Osteonecrosis must not be overlooked

Recovery from COVID-19 is not always uneventful, especially in critically ill hospitalized patients. Persistent symptoms including fatigue/ weakness, shortness of breath, anxiety, and depression have been described at one-year follow-up. Furthermore, symptoms from the musculoskeletal system like joint pain or stiffness are underreported in studies with long-term follow-up of up to one year. Infection with SARS-CoV-2 itself has been associated with endothelial damage, and together with high-dose corticosteroid treatment, it is predisposed to the dissemination of microthrombi and the development of femoral head osteonecrosis (FHOn), as it has been shown during the previous (2003-2004) coronavirus outbreaks. A resurgence of FHOn cases is anticipated but this is not reflected in the existing studies with long-term follow-up. Prompt diagnosis is critical for early treatment and possibly for the hip joint preservation. Patients with COVID-19 treated with corticosteroids should be screened for avascular necrosis early after discharge from the hospital. Every healthcare worker involved in the management of these patients should maintain a high level of suspicion and should be alert when patients report symptoms such as vague aches at the buttocks, hip area, adductors, and/or above the knee. Studies are needed to identify risk factors for FHOn including disease severity, type of steroid, cumulative dose, and duration of treatment.

Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis: a Bayesian network meta-analysis

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function.

AREAS OF CONTROVERSY

Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified.

GROWING POINTS

To provide an overview over current treatment options for ONFH compares their failure rates and conversion to total hip arthroplasty (THA) rates.

AREAS TIMELY FOR DEVELOPING RESEARCH

Core decompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.

Osteonecrosis of the Femoral Head Safely Healed with Autologous, Expanded, Bone Marrow-Derived Mesenchymal Stromal Cells in a Multicentric Trial with Minimum 5 Years Follow-Up

Background: Osteonecrosis (ON) of the femoral head represents a potentially severe disease of the hip where the lack of bone regeneration may lead to femoral head collapse and secondary osteoarthritis, with serious pain and disability. The aim of this European, multicentric clinical trial was to prove safety and early efficacy to heal early femoral head ON in patients through minimally invasive surgical implantation of autologous mesenchymal stromal cells (MSC) expanded from bone marrow (BM) under good manufacturing practices (GMP). Methods: Twenty-two patients with femoral head ON (up to ARCO 2C) were recruited and surgically treated in France, Germany, Italy and Spain with BM-derived, expanded autologous MSC (total dose 140 million MSC in 7 mL). The investigational advanced therapy medicinal product (ATMP) was expanded from BM under the same protocol in all four countries and approved by each National Competent Authority. Patients were followed during two years for safety, based on adverse events, and for efficacy, based on clinical assessment (pain and hip score) and imaging (X-rays and MRIs). Patients were also reviewed after 5 to 6 years at latest follow-up for final outcome. Results: No severe adverse event was recalled as related to the ATMP. At 12 months, 16/20 per protocol and 16/22 under intention-to-treat (2 drop-out at 3 and 5 months) maintained head sphericity and showed bone regeneration. Of the 4 hips with ON progression, 3 required total hip replacement (THR). At 5 years, one patient (healed at 2 years visit) was not located, and 16/21 showed no progression or THR, 4/21 had received THR (all in the first year) and 1 had progressed one stage without THR. Conclusions: Expanded MSCs implantation was safe. Early efficacy was confirmed in 80% of cases under protocol at 2 years. At 5 years, the overall results were maintained and 19% converted to THR, all in the first year.

Pathophysiology of Hip Disorders in Patients with Mucopolysaccharidosis IVA

Patients with mucopolysaccharidoses IVA (MPS IVA) have a progressive accumulation of the specific glycosaminoglycans (GAGs): chondroitin-6-sulfate (C6S) and keratan sulfate (KS), leading to the degeneration of the cartilage matrix and its connective tissue perturbing the regular microarchitecture of cartilage and successively distorting bone ossification and growth. Impaired cartilage quality and poor bone mineralization lead to serious hip disorders in MPS IVA patients. Although hip dysplasia is seen widely in musculoskeletal abnormality of this disorder, the pathophysiology of the hip bone and cartilage morphology in these patients remains unclear. Until now, no systemic study of the hip joints in MPS IVA has been reported by using the combined images of plain film radiographs (PFR) and Magnetic Resonance Imaging (MRI). This study aimed to assess the bony and cartilaginous features of hip joints and to explore the potentially related factors of femoral head osteonecrosis (FHN) and hip subluxation/dislocation in patients with MPS IVA. Hip joints in MPS IVA patients were retrospectively reviewed, based on the findings of PFR and MRI data from 2014 to 2019. Demographic information was also collected and analyzed with imaging measurements. A total of 19 patients (eight boys and 11 girls) were recruited, and 38 hip joints in these patients were examined. Eleven patients (57.9%) had FHN. FHN patients were statistically compared with those without FHN. Correlations between cartilaginous femoral head coverage (CFHC) and acetabular index (AI), cartilaginous AI (CAI), or neck-shaft angle (NSA) were investigated in patients with hip subluxation or dislocation. The greater cartilaginous coverage of the hips than their osseous inherency was observed. Significant correlation was observed between CFHC and AI (r =-0.351, p = 0.049) or CAI (r =-0.381, p = 0.032). Severe subluxations or dislocations were more likely to be present in those with more dysplastic bony and cartilaginous hips. In conclusion, our study provides the first systemic description of bony and cartilaginous characteristics in the hip morphology of MPS IVA patients. We have demonstrated that plain radiography alone leads to a misunderstanding of hip morphology and that MRI measurements with PFR are an essential tool to evaluate the 'true' characterization of hips for MPS IVA patients.

Effect of Allogeneic Cell-Based Tissue-Engineered Treatments in a Sheep Osteonecrosis Model

Osteonecrosis of the femoral head (ONFH) is defined as a tissue disorder and successive subchondral bone collapse resulting from an ischemic process, which may progress to hip osteoarthritis. Cell therapy with multipotent bone marrow mesenchymal stromal cells (BM-MSC) of autologous origin appears to be safe and has shown regenerative potential in previous preclinical and clinical studies. The use of allogeneic cells is far more challenging, but may be a promising alternative to use of autologous cells. Moreover, an optimized dosage of cells from an allogeneic source is needed to obtain off-the-shelf tissue engineering products (TEPs). The purpose of this study was to evaluate the efficacy of a TEP composed of undifferentiated ex vivo expanded BM-MSC of allogeneic origin, combined with bone matrix particles in variable doses. A comparative analysis of TEP's bone regenerative properties against its autologous counterpart was performed in an early-stage ONFH preclinical model in mature sheep. Allogeneic BM-MSC groups demonstrated bone regeneration capacity in osteonecrotic lesions equivalent to autologous BM-MSC groups 6 weeks after treatment. Likewise, stimulation of bone regeneration by a low cell dose of 0.5 × 10⁶ BM-MSC/cm³ was equivalent to that of a high cell dose, 5 × 10⁶ BM-MSC/cm³. Neither local nor systemic immunological reactions nor tumorigenesis were reported, strengthening the safety profile of allogeneic BM-MSC therapy in this model. Our results suggest that low-dose allogeneic BM-MSC is sufficient to promote bone regeneration in femoral head osteonecrotic lesions, and should be considered in translation of new allogeneic cell-based TEPs to human clinics. Impact statement Cell therapy and tissue engineering hold promise as novel regenerative therapies for musculoskeletal diseases, and particularly in bone regeneration strategies. In this article, we report the evaluation of the efficacy of an allogeneic cell-based tissue engineering product (TEP) in an early-stage osteonecrosis of the femoral head preclinical model in skeletally mature sheep. Moreover, we demonstrate its bone regeneration capacity and safety in vivo and its equivalence to autologous counterparts. These findings have important implications for the translation of new allogeneic cell-based TEPs to human clinics.

Perspectives on the Social, Physical, and Emotional Impact of Living With Perthes' Disease in Children and Their Family: A Mixed Methods Study

Aim. To determine the social, physical, and emotional impact of living with Perthes’ disease on affected children and their family (caregivers). Patients and Methods. Through a mixed methods approach, we interviewed 18 parents and explored the perspectives of 12 children affected by Perthes’ disease (mean = 7.1 years, SD = ±4.1 years) using a survey tool. Thematic analysis of parents’ interviews provided an insight into disease-specific factors influencing patients and family’s daily life activities. Using the childhood survey tool, good and bad day scores were analyzed using MANOVA (multivariate analysis of variance). Results. Thematic analysis of the parent interviews (main themes n = 4) identified a marked effect of the disease on many facets of the child’s life, particularly pain and the impact on sleep, play, and school attendance. In addition, the interviews identified a negative effect on the family life of the parents and siblings. Children indicated that activities of daily living were affected even during “good days” (P < .05), but pain was the key limiting factor. Conclusion. Perthes’ disease negatively affects the social, physical, and emotional well-being of children and their family. These findings provide outcome domains that are important to measure in day-to-day care and add in-depth insight into the challenges caused by this disease for health care professionals involved in clinical management.

Ischemic femoral head osteonecrosis in a piglet model causes three dimensional decrease in acetabular coverage

Legg-Calve-Perthes disease (LCPD) is a childhood form of ischemic osteonecrosis marked by development of severe femoral head deformity and premature osteoarthritis. The pathogenesis of femoral head deformity has been studied extensively using a piglet model of ischemic osteonecrosis, however, accompanying acetabular changes have not been investigated. The purpose of this study was to determine if acetabular changes accompany femoral head deformity in a well-established piglet model of LCPD and to define the acetabular changes using three dimensional computed tomography (3-D CT) and modeling. Twenty-four piglets were surgically induced with ischemic osteonecrosis on the right side. The contralateral hip was used as control. At 8 weeks postoperative, pelvi were retrieved and imaged with CT. Custom software was used to measure acetabular morphologic parameters on 3-D CT images. Moderate to severe femoral head deformities were present in all animals. Acetabula with accompanying femoral head deformity had a significant decrease in acetabular version and tilt (p < 0.001) and in coverage angle in the superior, posterior, and inferior quadrants (p < 0.05). These findings indicate that the development of femoral head deformity following ischemic osteonecrosis produces specific and predictable changes to the shape of the acetabulum. Acetabular changes described in patients with LCPD were observed in the piglet model. This model may serve as a valuable tool to elucidate the relationship between femoral head and acetabular deformities. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1173-1177, 2018.

Survival Analysis after Core Decompression in Association with Platelet-Rich Plasma, Mesenchymal Stem Cells, and Synthetic Bone Graft in Patients with Osteonecrosis of the Femoral Head

Purpose  The aim of this study was to report the rate of survivorship in patients with osteonecrosis of the femoral head treated with core decompression in association with mesenchymal stem cells (MSCs) implantation, platelet-rich plasma (PRP) injection, and synthetic bone graft. Methods  We evaluated 24 hips in 16 patients, according to Ficat classification, treated by core decompression, injection of PRP and MSCs, and backfilling of the core tract with synthetic bone graft. Survivorship was estimated using Kaplan-Meier curves. Results  The survivorship of core decompression in association with the procedure is 50% at 75 months of follow-up. The survival rate was 80% for patients in early stage and 28.6% for patients in advanced stage at 75 months. When we compared Kaplan-Meier survival curves of patients in stage III + IV and patients in stage I + II, we noticed that the survival functions are statistically different ( p  < 0.05, log-rank test), particularly in stage I + II where we had a greater surviving core decompression, in comparison to patients in stage III + IV. Conclusion  This technique is safe and good preliminary results were obtained in patients with early stages of the disease with no reported complications. Level of Evidence  Level IV, therapeutic case series.

A reproducible method for the isolation and expansion of ovine mesenchymal stromal cells from bone marrow for use in regenerative medicine preclinical studies

The use of multipotent mesenchymal stromal cells (MSCs) as candidate medicines for treating a variety of pathologies is based on their qualities as either progenitors for the regeneration of damaged tissue or producers of a number of molecules with pharmacological properties. Preclinical product development programmes include the use of well characterized cell populations for proof of efficacy and safety studies before testing in humans. In the field of orthopaedics, an increasing number of translational studies use sheep as an in vivo test system because of the similarities with humans in size and musculoskeletal architecture. However, robust and reproducible methods for the isolation, expansion, manipulation and characterization of ovine MSCs have not yet been standardised. The present study describes a method for isolation and expansion of fibroblastic-like, adherent ovine MSCs that express CD44, CD90, CD140a, CD105 and CD166, and display trilineage differentiation potential. The 3-week bioprocess proposed here typically yielded cell densities of 1.4 × 10⁴ MSCs/cm² at passage 2, with an expansion factor of 37.8 and approximately eight cumulative population doublings. The osteogenic potential of MSCs derived following this methodology was further evaluated in vivo in a translational model of osteonecrosis of the femoral head, in which the persistence of grafted cells in the host tissue and their lineage commitment into osteoblasts and osteocytes was demonstrated by tracking enhanced green fluorescent protein-labelled cells. Copyright © 2016 John Wiley & Sons, Ltd.

Combining Concentrated Autologous Bone Marrow Stem Cells Injection With Core Decompression Improves Outcome for Patients with Early-Stage Osteonecrosis of the Femoral Head: A Comparative Study

The management of early-stage osteonecrosis of the femoral head (ONFH) remains challenging. This study aimed to evaluate the effects of core decompression and concentrated bone marrow implantation on ONFH. The study recruited 28 hips with early ONFH randomly assigned into two groups of core decompression with (group A) and without (group B) bone marrow injection. Patients were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, Visual Analogue Scale (VAS) pain index, and MRI. The mean WOMAC and VAS scores in all patients improved significantly (P<0.001). MRI showed a significant improvement in group A (P=0.046) and significant worsening in group B (P<0.001). Bone marrow stem cell injection with core decompression can be effective in early ONFH.

Experimental rat model for alcohol-induced osteonecrosis of the femoral head

Alcohol-induced osteonecrosis of the femoral head (ONFH) is observed in alcohol abusers and patients with alcoholic fatty liver disease. It has been reported that Toll-like receptor 4 (TLR4) signalling plays a crucial role in the pathogenesis of alcoholic fatty liver disease. We previously reported a corticosteroid-induced ONFH rat model, and suggested that TLR4 signalling contributes to the pathogenesis of ONFH. Thus, it is thought that the pathogenesis of alcohol-induced ONFH is probably similar to that of corticosteroid-induced ONFH. The aim of this study was to develop a new animal model for alcohol-induced ONFH and to evaluate the relationship between the pro-inflammatory response via TLRs and the development of ONFH in rats. Male Wistar rats were fed a Lieber–DeCarli liquid diet containing 5% ethanol (experimental group) or dextran (control group) for 1–24 weeks. Histopathological and biochemical analyses were performed. Feeding the ethanol-containing liquid diet resulted in the development of ONFH with hepatic steatosis, hepatic dysfunction and hyperlipidaemia, whereas feeding the dextran-containing diet did not cause ONFH. However, we could not recognize any relationship between the pro-inflammatory response via TLR4 and the development of alcohol-induced ONFH. Thus in this study we have developed a new rat model for alcohol-induced ONFH based on the feeding of an ethanol liquid diet. ONFH was observed within seven days from the start of feeding with 5% ethanol-containing liquid diet. Although this was linked to hepatic steatosis, a TLR4 association was not a feature of this model.

White Matter Lesions in Femoral Head Osteonecrosis patients: Manifestation of vascular disease or not?

BACKGROUND

Osteonecrosis has been associated with the presence of white matter lesions. The objective of this study was to investigate the association between macro- and micro- vascular disease and white matter lesions.

METHODS

Sixty-four patients with femoral head osteonecrosis were assessed during a cross sectional study in our university-based hospital. A vascular 'profile' was obtained for each patient and included measurement of plasma lipids, fundoscopic examination and common carotid artery triplex ultrasonography. All patients had brain MRI to assess for presence of white matter lesions. The two groups formed, with and without white matter lesions, were compared in order to define the association between white matter lesions and vascular disease.

RESULTS

Patients without white matter lesions had more frequently corticosteroid induced osteonecrosis. There was no difference in the two groups with respect to intima media thickness and ApoB/ApoA1 ratio. Only one of our patients demonstrated retinopathy.

CONCLUSIONS

There is no evidence of concurrent macro- and micro- vascular pathology in young patients with white matter lesions and femoral head osteonecrosis. Cortisone appears to have a 'protective' effect against occurrence of white matter lesions.

Cryoinsult parameter effects on the histologically apparent volume of experimentally induced osteonecrotic lesions

Investigation of femoral head osteonecrosis would benefit from an animal model whose natural history includes progression to bony collapse of a segmental necrotic lesion. The bipedal emu holds attraction for systematic organ-level study of collapse mechanopathology. One established method of experimentally inducing segmental lesions is liquid nitrogen cryoinsult. Four cryoinsult parameters-hold temperature, freeze duration, freeze/thaw repetition, and thaw duration-were investigated to determine their individual and combined effects on resulting necrotic lesion morphology. 3D distributions of histologically apparent osteocyte necrosis from 24 emus receiving varying cryoinsults were used to develop univariate and multivariate linear regression models relating resulting necrotic lesion morphology to particular cryoinsult input parameters. These models were then applied to predict lesion size in four additional emus receiving differing input cryoinsults. The best multivariate regression model predicted lesion volumes that were accurate to better than 8% of overall emu femoral head volume. The hold temperature during cryoinsult was by far the most influential cryoinsult input parameter. The utility of this information is to enhance the consistency and predictability of cryoinsult-induced segmental lesion size for the purposes of systematic laboratory studies at the whole-organ level.