Abstract
Osteonecrosis of the femoral head (ONFH) is a debilitating disease with major social and economic impacts. It frequently affects relatively young adults and has a predilection for rapid progression to femoral head collapse and end-stage hip arthritis. If not diagnosed and treated properly in the early stages, ONFH has devastating consequences and leads to mandatory total hip arthroplasty. The pathophysiology of non-traumatic ONFH is very complex and not fully understood. While multiple risk factors have been associated with secondary ONFH, there are still many cases in which a clear etiology cannot be established. Recognition of the prothrombotic state as part of the etiopathogeny of primary ONFH provides an opportunity for early medical intervention, with implications for both prophylaxis and therapy aimed at slowing or stopping the progression of the disease. Hereditary thrombophilia and hypofibrinolysis are associated with thrombotic occlusion of bone vessels. Anticoagulant treatment can change the natural course of the disease and improve patients’ quality of life. The present work focused on highlighting the association between hereditary thrombophilia/hypofibrinolysis states and ONFH, emphasizing the importance of identifying this condition. We have also provided strong arguments to support the efficiency and safety of anticoagulant treatment in the early stages of the disease, encouraging etiological diagnosis and prompt therapeutic intervention. In the era of direct oral anticoagulants, new therapeutic options have become available, enabling better long-term compliance.
Highlights
Osteonecrosis, avascular necrosis or aseptic necrosis of bone are all defined as bone cell death following the compromise of blood flow to the bone [1]
Glueck et al [3] and Orth et al [4] hypothesized that the intravascular coagulation which occurs in the thrombophilia-hypofibrinolysis states determines venous thrombotic occlusion—which leads initially to increased intraosseous venous pressure and subsequently to impaired arterial blood flow and bone ischemia
In patients with ONFH and hereditary thrombophilia-hypofibrinolysis, the role of anticoagulant treatment is to limit the progression of intraosseous venous thrombosis, allowing the spontaneous lysis of thrombi
Summary
Osteonecrosis, avascular necrosis or aseptic necrosis of bone are all defined as bone cell death following the compromise of blood flow to the bone [1]. Ligamentum teres is an intra-articular ligament between the femoral head and acetabulum Traumatic lesions such as displaced femoral neck fractures and hip dislocations severely compromise the vascularity around the femoral head, leading to bone ischemia and ONFH [6]. Recognition of the prothrombotic state as part of the etiopathogeny of primary ONFH provides an opportunity for early medical intervention, with implications for both prophylaxis and therapy aimed at slowing or stopping the progression of the disease This is all the more important, as studies show that the highest incidence of nontraumatic ONFH is in relatively young adults (males aged 20 to 50 years) [6,23,24], and that hip joint destruction rapidly progresses into end-stage hip arthritis, requiring surgical intervention [25]. Since patients with inherited thrombophilia and hypofibrinolysis benefit from anticoagulant treatment in prophylaxis and treatment of thrombotic events, we focused on anticoagulant use in primary ONFH patients with a hereditary thrombophilia—hypofibrinolysis background
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