Association Research Circulation Osseous Stage Research Articles

Mid-term Clinical Outcomes of "Light Bulb" Core Decompression with Arthroscopic Assistance in Peri-collapse Osteonecrosis of the Femoral Head: A Retrospective Comparative Study.

Nontraumatic osteonecrosis of the femoral head (ONFH) is commonly encountered in orthopedics. Without early clinical intervention, most patients with peri-collapse of the ONFH will develop femoral head necrosis and eventually require hip replacement surgery. The aim of this study is to evaluate clinical outcomes in patients with ONFH who underwent "light bulb" core decompression (CD) with arthroscopic assistance and to compare them with the outcomes of those treated with traditional procedures. A retrospective review of patients with Stage II and IIIA (Peri-collapse) radiographic findings based on the Association Research Circulation Osseous (ARCO) stage for ONFH who underwent "light bulb" CD with or without arthroscopic assistance by a single-surgeon team between March 2014 and December 2018 was performed. All patients were followed up for a minimum of 2 years. The visual analogue scale (VAS) pain score, Harris hip score (HHS), and radiological imaging were evaluated. The categorical parameters were analyzed by chi-square test and the continuous variables conforming to a normal distribution were analyzed by Student's t-test. The study included a total of 39 patients (18 and 21 patients in the with and without arthroscopic assistance groups, respectively), with a mean age of 40.3 years and a mean follow-up of 22.2 months. Overall, there was a better VAS score in the arthroscopic assistance group than in the control group (p < 0.05), There was a significant difference in HHS (80.1 ± 9.2 vs 75.1 ± 12.7) at the last follow-up (p < 0.05). The rate of good and excellent outcomes was 94%. Similarly, there was no significant difference in the total rate of complications or conversion to THA. With arthroscopic assistance, "light bulb" CD could be achieved via hip arthroscopy with less trauma, and it offered the opportunity for more precise evaluation and monitoring for therapy and yielded better VAS scores after surgery and better hip function outcomes at the last follow-up.

Comparison of outcomes after total hip arthroplasty between patients with osteonecrosis of the femoral head in Association Research Circulation Osseous stage III and stage IV: a five-year follow-up study

BackgroundNo large cohort study has evaluated the surgical outcomes of THA between different stages of ONFH patients. This study aimed to compare the surgical outcomes of ONFH patients who underwent THA in ARCO stage III versus IV, in terms of operative parameters, one-year hip function assessments and postoperative at least five-year complications, to inform optimized management of ONFH.MethodFrom our prospectively collected database, 876 patients undergoing THA between October 2014 and April 2017 were analyzed and divided into ARCO stage III group (n = 383) and ARCO stage IV group(n = 493). Details of demographics, medical record information, adverse events and clinical scores of both groups were collected and compared. Proper univariate analysis was used for the analysis.ResultThere were no statistically significant differences in baseline characteristics between the two groups. Compared to ARCO stage IV patients, ARCO stage III patients showed a shorter operative time (p < 0.01), less bleeding (p < 0.01), fewer one-year readmissions (p = 0.026) and complications (p = 0.040), and significantly higher HHS (p < 0.01) one year after THA. In addition, ARCO stage IV patients seem more likely to suffer prosthesis dislocation (p = 0.031).ConclusionAlthough ARCO stage IV patients in the study cohorts appeared to suffer more one-year complications, no significant difference was observed at long-term follow-up. Enhanced clinical guidance on preventing early prosthesis dislocation may help improve the prognosis of final-stage ONFH patients.

Analysis of the natural collapse course of non-traumatic osteonecrosis of the femoral head based on the matrix model

BackgroundThere are many predictions about the progression of natural collapse course of osteonecrosis of the femoral head. Here, we aimed to combine the three classical prediction methods to explore the progression of the natural collapse course.MethodsThis retrospective study included 127 patients admitted to our hospital from October 2016 to October 2017, in whom the femoral head had not collapsed. Logistic regression analysis was performed to determine the collapse risk factors, and Kaplan–Meier survival curves were used for femoral head survival analysis. The collapse rate of the femoral head was recorded within 5 years based on the matrix model. The specificity of the matrix model was analyzed using the receiver operating characteristic curve.ResultsA total of 127 patients with a total of 202 hips were included in this study, and 98 hips collapsed during the follow-up period. Multivariate logistics regression analysis showed that the predictive ability of the matrix model was stronger than Association Research Circulation Osseous staging, Japanese Investigation Committee classification, and area (P < 0.05). Kaplan–Meier survival curve showed that the median survival time of femoral head in patients was 3 years. The result of the receiver operating characteristic curve analysis showed that the area under the curve (AUC) of the matrix model had better predictive value (AUC = 0.771, log-rank test: P < 0.001).ConclusionWe creatively combined the three classical prediction methods for evaluating the progression of the natural collapse course based on the matrix model and found that the higher the score of the matrix model, the higher the femoral head collapse rate. Specifically, the matrix model has a potential value in predicting femoral head collapse and guiding treatment selection.

Serum glutathione peroxidase 4 as a novel biomarker for nontraumatic osteonecrosis of the femoral head: A retrospective case-control study.

There are no serum biomarkers available in nontraumatic osteonecrosis of the femoral head in clinical practice. This study aimed to evaluate the clinical value of serum glutathione peroxidase 4 in nontraumatic osteonecrosis of the femoral head. This retrospective study analyzed serum glutathione peroxidase 4 levels and clinical data of 80 patients with nontraumatic osteonecrosis of the femoral head and 80 healthy controls between August 2021 and May 2022. Serum glutathione peroxidase 4 levels were analyzed using an enzyme-linked immunosorbent assay. The Association Research Circulation Osseous classification system determined disease progression. Clinical severity was assessed by Harris hip score and visual analogue scale. Correlations between serum glutathione peroxidase 4 and disease progression as well as clinical severity were evaluated statistically. The diagnostic accuracy of serum glutathione peroxidase 4 in nontraumatic osteonecrosis of the femoral head was determined using receiver operating characteristic analysis. The baseline characteristics of participants between 2 groups were comparable. Patients with nontraumatic osteonecrosis of the femoral head displayed a decreased glutathione peroxidase 4 level compared with healthy controls (11.87 ± 2.76 μU/mL vs 16.54 ± 4.89 μU/mL, P < .01). The levels of glutathione peroxidase 4 were inversely correlated with Association Research Circulation Osseous stage (P < .01) and visual analogue scale scores (P < .01), and positively correlated with Harris score (P < .01). Receiver operating characteristic analyses showed that area under curves of glutathione peroxidase 4 was 0.808 (95% CI 0.721-0.858) and 0.847 (95% CI 0.743-0.951) with regard to diagnosis and collapse prediction in nontraumatic osteonecrosis of the femoral head, respectively. Serum glutathione peroxidase 4 could serve as a novel biomarker for diagnosing nontraumatic osteonecrosis of the femoral head and predicting collapse of the femoral head.

Femoral Head Osteonecrosis: Computed Tomography Not Needed to Identify Collapse When Using the Association Research Circulation Osseous Staging System

BackgroundThe 2019 Revised Association Research Circulation Osseous (ARCO) Staging Criteria for Osteonecrosis of the Femoral Head (ONFH) only requires plain radiographs and magnetic resonance imaging (MRI) to diagnose and stage ONFH; however, the effectiveness of the 2019 ARCO criteria in the absence of computed tomography (CT) scans has not been investigated. Therefore, the purpose of this study was to evaluate whether CT scanning is a necessary modality for diagnosing/staging ONFH using the ARCO staging system. More specifically, do CT scans help differentiate pre- and post-collapse lesions more than MRI scans? MethodsA study was conducted on 228 ONFH patients diagnosed between January 1, 2008, and December 31, 2018, at a single academic medical center. CT and MRI scans were reviewed by the senior author and other contributors. The ONFH classification was compared between the 2 scans to determine if CT scans were able to further differentiate staging of collapsed lesions vs MRI scans. ResultsA diagnosis of ONFH was made by MRI first in 57% (129/228) while 21% (48/228) used MRI and CT simultaneously. Only 22% (51/228) of cases were diagnosed by CT scans first. There were no cases where collapse was found by a CT scan that were not diagnosed by standard x-rays and/or MRIs. ConclusionsCT scans are not a useful adjunct for diagnosing or treating ONFH and are not necessary if MRI is ordered when using the Revised ARCO Staging System for ONFH diagnosis.

Plasma 8-OHdG act as a biomarker for steroid-induced osteonecrosis of the femoral head

BackgroundOxidative stress was closely related to the occurrence and development of Steroid-induced osteonecrosis of the femoral head (SIONFH). 8-hydroxy-2'-deoxyguanosine (8-OHdG) is a important index of oxidative stress. The aim of this study is to investigate the role of 8-OHdG in the development of SIONFH.MethodsFrom May 2021 and November 2021, 33 patients diagnosed with SIONFH and 26 healthy controls were recruited in this study. Assessment included the radiography and pathology evaluation of clinical bone tissue, expression position and level of 8-OHdG, level of plasma 8-OHdG, as well as the receiver operating characteristic (ROC) curve.ResultsWe observed that expression levels of 8-OHdG in bone samples decreased with Association Research Circulation Osseous (ARCO) stages. Plasma 8-OHdG levels were significantly increased in the SIONFH group compared to the healthy control group. Plasma 8-OHdG level of pre-collapse patients was higher than that of post-collapse patients, the decreased plasma 8-OHdG level was related to higher ARCO stages.ConclusionPlasma 8-OHdG may represent potential biomarkers during SIONFH at different stages. Higher plasma 8-OHdG levels indicated early stage of SIONFH. The current study provided new clues for early diagnosis and treatment for SIONFH.

Alteration in Microcirculation With Osteonecrosis of the Femoral Head: A Study of Dynamic Contrast-Enhanced MRI.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is commonly used in clinical practice to detect tumor blood supply, and it has recently been applied to assess skeletal vasculature. In this study, we retrospectively analyzed DCE-MRI data from 37 patients with osteonecrosis of the femoral head to evaluate alterations in microvascular circulation of the femoral head. Time-intensity curves (TICs) in the region of interest were classified into different lesion stages. In the greater trochanter area, extracellular space volume per unit volume of tissue was significantly higher in Association Research Circulation Osseous (ARCO) stage III than in ARCO stage II (P<.05 and power ≥ 0.8), while other parameters showed no statistical difference (P>.05 and/or power < 0.8). In the necrotic area, contrast enhancement ratio and maximum slope of increase were significantly lower in ARCO stage III than in ARCO stage II (P<.05 and power ≥ 0.8), while other parameters showed no statistical difference (P>.05 and/or power < 0.8). In the repair reaction area, all parameters were significantly higher in ARCO stage III than in ARCO stage II (P<.05 and power ≥ 0.8). TIC classification showed that the greater trochanter area mainly exhibited type C (plateau type), the necrotic area mainly exhibited type B (out-flow type), and the repair reaction area mainly exhibited type A (inflow type). We believe that the exchange capacity of the vessels has a much greater impact on femoral head necrosis than the number of vessels, while the generation of the repair area greatly affects the prognosis of femoral head necrosis. These findings suggest that DCE-MRI can provide a good assessment of osteonecrosis of the femoral head perfusion and can serve as a new reference for clinical treatment decisions. [Orthopedics. 2024;47(2):e73-e78.].

Decreased serum 4-Hydroxynonenal level as a biomarker for the progression of steroid-induced osteonecrosis of the femoral head

BackgroundOsteonecrosis of the femoral head (ONFH) is becoming a prevalent global health problem. 4-Hydroxynonenal (4-HNE) serves as a common marker of oxidative stress. This study aims to study the potential role of 4-HNE in the progression of steroid-induced osteonecrosis of the femoral head (SIONFH).MethodBetween April 2021 and December 2021, 64 subjects were enrolled in this cross-sectional case‒control study. Thirty-six patients were grouped based on the Association Research Circulation Osseous (ARCO) classification, and 28 healthy volunteers without hip pain or any lesions shown in anteroposterior and frog-leg lateral pelvic radiographs served as the normal control group. Bone hematoxylin–eosin (HE) staining, microcomputed tomography (micro-CT), immunohistochemistry, and levels of plasma 4-HNE were evaluated.ResultsThe 4-HNE level was higher in the SIONFH group than in the normal control group (P < 0.001), and 4-HNE levels were significantly higher in SIONFH patients in the early stage of disease (stage II). The 4-HNE level was negatively correlated with ARCO stage (r = − 0.6875, P < 0.001). Immunohistochemistry revealed the presence of 4-HNE in the trabecular bone, osteocytes, and bone marrow.ConclusionThe 4-HNE level is negatively associated with ARCO stages. Lower levels of 4-HNE may serve as a critical biomarker for the progression of SIONFH.

Updating Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH), a condition characterized by the presence of a necrotic bone lesion in the femoral head, is caused by a disruption in the blood supply. Its occurrence is more common in young and middle-aged adults and it is the main reason for performance of total hip arthroplasty in this age group. Its incidence is increasing along with increased use of glucocorticoids for management of adjuvant therapy for treatment of leukemia as well as organ transplantation and other myelogenous diseases. Current information on etiology and pathogenesis, as well as natural history, stage system, and treatments is provided in this review. A description of the Association Research Circulation Osseous (ARCO) criteria for classification of glucocorticoids- and alcohol-associated ONFH, 2019 ARCO staging system, and 2021 ARCO classification using computed tomography for the early stages of ONFH is also provided.

Core decompression vs. allogenic non-vascularized bone grafting in patients with osteonecrosis of the femoral head.

Core decompression and allogenic non-vascularized bone grafting are used in the early stage of osteonecrosis of the femoral head for a period. Since the comparison of the core decompression and allogenic non-vascularized bone grafting are less reported, the purpose of our study was to investigate the difference of two procedures in patients with the osteonecrosis of the femoral head. Between January 2018 and January 2019, 59 patients (64 hips) were divided into core decompression group and non-vascularized bone grafting group according to their procedures. The primary outcomes are visual analog score (VAS) and Harris hip score. Survivorship was analyzed with the collapse of the femoral head or conversion to total hip arthroplasty (THA) as the endpoint. At the final follow-up, two hips underwent THA in the core decompression group and three hips in the allogenic non-vascularized bone grafting group. The radiographic survival rates were 76.9% and 77.3%, respectively, in both groups. The VAS of the core decompression group was 6.08 ± 1.164 and 3.30 ± 1.431 before and 2 years after operation (P < 0.05), respectively. The VAS of the allogenic non-vascularized bone grafting group was 6.00 ± 1.209 and 3.15 ± 1.537 before and 2 years after operation (P < 0.05), respectively. The Harris hip score of the core decompression group was 52.49 ± 6.496 before operation, and 2 years after operation, it increased by 81.14 ± 8.548 (P < 0.05); The Harris hip score of allogenic the non-vascularized bone grafting group was 53.56 ± 5.925 and 81.33 ± 7.243 before and 2 years after operation (P < 0.05), respectively. In the core decompression group, body mass index (BMI) >25 kg/m2 was correlated with the collapse of femoral head or conversion to THA [P < 0.05; 95% confidence interval (CI), 0.006-1.334], and Association Research Circulation Osseous (ARCO) III was correlated with the collapse of femoral head or conversion to THA (P < 0.05; 95% CI, 2.514-809.650). In the allogenic non-vascularized bone grafting group, age, BMI, and ARCO stage were significantly associated with the collapse of femoral head or conversion to THA (P > 0.05). The clinical survival rate of the femoral head in the core decompression group was slightly better than that in the allogenic non-vascularized bone grafting group. There was no significant difference in the radiographic survival rate of the femoral head between the two groups. Both groups can alleviate pain and improve functional of patients, but there was no significant difference in the degree of improvement. In the core decompression group, BMI >25 kg/m2 and ARCO III correlated with the collapse of femoral head or conversion to THA. In the allogenic non-vascularized bone grafting group, no association was found between age, BMI, and ARCO stage and the collapse of femoral head or conversion to THA. III.

What Is New in Stage 3 of the 2019 Revised Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head: A Relationship to Bone Resorption.

The aim of the study is to evaluate the stage 3 findings of the 2019 revision of the Association Research Circulation Osseous (ARCO) staging system for osteonecrosis of the femoral head between 3A and 3B and the relationship with bone resorption area. We retrospectively enrolled 87 patients with ARCO stage 3 osteonecrosis of the femoral head, divided into stage 3A (n = 73) and 3B (n = 14). The revised stage 3 findings included subchondral fracture, fracture in necrotic portion, and flattening of the femoral head and were compared between stage 3A and 3B. The association between these findings and the causative features of bone resorption area was also evaluated. All stage 3 cases had subchondral fractures. In stage 3A, these fractures were generated by crescent sign (41.1%) and by fibrovascular reparative zone in 58.9%; however, in stage 3B, fibrovascular reparative zone generated 92.9% of these fractures and crescent sign only 7.1% with statistical significance (P = 0.034). Necrotic portion fracture was noted in 36.7% and femoral head flattening was observed in 14.9% of all stage 3. Necrotic portion fracture (92.9% vs 26.0%) and femoral head flattening (71.4% vs 4.1%) were observed more frequently in stage 3B than 3A (P < 0.001). Almost all subchondral fractures by fibrovascular reparative zone (96.4%) and necrotic portion fracture (96.9%), and all femoral head flattening was presented with bone resorption area with expanding areas. The ARCO stage 3 descriptions reflect severity in this order: subchondral fracture, necrotic portion fracture, and femoral head flattening. More severe findings are usually associated with expanding bone resorption areas.

Long-term outcomes of arthroscopic synovectomy and core decompression through multiple small bone holes for early-stage avascular necrosis of the femoral head

ObjectiveThis study described a minimally invasive approach for the management of early-stage avascular necrosis of the femoral head, which integrated arthroscopic intra-articular decompression and core decompression by drilling multiple small holes.MethodA total of 126 patients with 185 hip avascular necrosis were included between March 2005 and January 2008, and the hips were classified, based on the Association Research Circulation Osseous staging system, into stage I (n = 43), stage II (n = 114), and stage III (n = 28). Arthroscopic intra-articular inspection and debridement, along with drilling of multiple small holes for core decompression, were performed. The Modified Harris hip score system and radiographs were used to assess the pre- and post-surgery outcomes.ResultsOne hundred and three patients (involving 153 hips) were followed up successfully for an average of 10.7 ± 3.4 years (range: 9–12 years). After surgery, the overall survival rate was 51.6% (79 hips), and the clinical survival rates were 79%, 72%, 52%, 32%, and 10% for patients with stage I, IIa, IIb, IIc, and III, respectively. The outcomes of patients with Association Research Circulation Osseous Stages I or IIA were better than those of other stages, while hips with a large necrotic area had poor results. This approach preserved the original biomechanical strength of the femoral head after core decompression and eliminated arthritis factors in the hip joint.ConclusionThe core decompression with multiple small-size holes is an effective method for treating early-stage avascular necrosis of the femoral head, particularly in those with pathological changes in the hip joint.Level of evidenceTherapeutic study, Level IV.

The indications for core decompression surgery in patients with ARCO stage I-II osteonecrosis of the femoral head: a new, comprehensive prediction system

BackgroundCore decompression (CD) is considered the most popular treatment method for patients with Association Research Circulation Osseous (ARCO) stage I-II osteonecrosis of the femoral head (ONFH). However, the definitive indication for CD is currently not well established.MethodsThis was a retrospective cohort study. Patients who were diagnosed with ARCO stage I-II ONFH and who underwent CD were included. According to the prognosis, the patients were divided into two groups: collapse of the femoral head after CD and noncollapse of the femoral head. Independent risk factors for the failure of CD treatment were identified. Subsequently, a new scoring system that included all these risk factors was built to help estimate the individual risk of CD failure in patients who were planning to undergo CD.ResultsThe study included 1537 hips after decompression surgery. The overall failure rate of CD surgery was 52.44%. Seven independent prognostic factors for failed CD surgery were identified, such as male sex (HR = 75.449; 95% confidence interval (CI), 42.863-132.807), Aetiology (Idiopathic HR = 2.762; 95% CI, 2.016–3.788, Steroid-induced HR = 2.543; 95% CI, 1.852–3.685), if the patient had a seated occupation (HR = 3.937; 95% CI, 2.712–5.716), age (HR = 1.045; 95% CI, 1.032–1.058), haemoglobin level (HR = 0.909; 95% CI, 0.897–0.922), disease duration (HR = 1.217; 95% CI, 1.169–1.267) and the combined necrosis angle (HR = 1.025; 95% CI, 1.022–1.028). The final scoring system included these seven risk factors, and the area under the curve of this scoring system was 0.935 (95% confidential interval = 0.922–0.948).ConclusionThis new scoring system might provide evidence-based medical proof for determining whether a patient with ARCO stage I - II ONFH might benefit from CD surgery. This scoring system is crucial for making clinical decisions. Consequently, this scoring system is recommended before CD surgery, which could help determine the potential prognosis of patients.

Attention fusion network with self-supervised learning for staging of osteonecrosis of the femoral head (ONFH) using multiple MR protocols.

Osteonecrosis of the femoral head (ONFH) is characterized as bone cell death in the hip joint, involving a severe pain in the groin. The staging of ONFH is commonly based on Magnetic resonance imaging and computed tomography (CT), which are important for establishing effective treatment plans. There have been some attempts to automate ONFH staging using deep learning, but few of them used only MRimages. To propose a deep learning model for MR-only ONFH staging, which can reduce additional cost and radiation exposure from the acquisition of CTimages. We integrated information from the MR images of five different imaging protocols by a newly proposed attention fusion method, which was composed of intra-modality attention and inter-modality attention. In addition, a self-supervised learning was used to learn deep representations from a large amount of paired MR-CT dataset. The encoder part of the MR-CT translation network was used as a pretraining network for the staging, which aimed to overcome the lack of annotated data for staging. Ablation studies were performed to investigate the contributions of each proposed method. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of thenetworks. Our model improved the performance of the four-way classification of the association research circulation osseous (ARCO) stage using MR images of the multiple protocols by 6.8%p in AUROC over a plain VGG network. Each proposed method increased the performance by 4.7%p (self-supervised learning) and 2.6%p (attention fusion) in AUROC, which was demonstrated by the ablationexperiments. We have shown the feasibility of the MR-only ONFH staging by using self-supervised learning and attention fusion. A large amount of paired MR-CT data in hospitals can be used to further improve the performance of the staging, and the proposed method has potential to be used in the diagnosis of various diseases that require staging from multiple MRprotocols.

Adipose-derived stromal vascular fraction injection following core decompression and biochemistry artificial bone graft implantation in osteonecrosis of the femoral head.

To determine how adipose-derived stromal vascular fraction (SVF) injection following core decompression (CD) and biochemistry artificial bone graft implantation affects outcomes in patients with osteonecrosis of the femoral head (ONFH). A total of 19 patients (28 hips) with stage I-IIIA ONFH received adipose-derived SVF injection and combined core decompression and biochemistry artificial bone graft implantation, followed up for a minimum of two years. Disease progression was evaluated according to the Association Research Circulation Osseous (ARCO) staging system, and the change of the ratio of the necrotic volume to femoral head volume was calculated with MRI before and after operation. At the last follow-up, 15 hips remained stable, and 13 hips had a progression, according to the ARCO staging system. A total of eight hips (5 with ARCO stage II and 3 with staged IIIA at baseline) progressed to post-collapse stage (stage IIIB-IV). In total, seven of eight hips with post-collapse stage and one with IIIA stage at follow-up converted to THAs in an average of 17.5months (range, 11-68months) postoperatively. The mean ratio of the necrotic lesion volume to the femoral head significantly decreased in hips with ARCO stage I (17.9 ± 3.0% to 9.8 ± 1.3%, p = 0.012, Δ necrosis ratio = 8.1 ± 4.2%) and stage II (22.7 ± 6.3% to 17.1 ± 9.4%, p = 0.001, Δ necrosis ratio = 5.7 ± 6.6%) at baseline. For the eight hips that progressed to post-collapse stage, the mean necrosis ratio increased from 27.4 ± 5.4% to 31.1 ± 4.0% (p = 0.146), Δ necrosis ratio = - 3.7 ± 3.9%. For the other 20 hips radiological survived, the mean necrosis ratio improved from 19.9 ± 4.4% to 11.8 ± 3.3% (p < 0.001), with Δ necrosis ratio = 8.1 ± 4.9%. Adipose-derived SVF injection following core decompression and biochemistry artificial bone graft implantation is safe and could effectively repair the necrosis lesion and delay disease progression in patients with early-stage ONFH.

Efficacy of Modified Lightbulb Technique by Percutaneous Femoral Neck-Head Fenestration Combined With Compacted Artificial Bone Graft for Treating Precollapse Osteonecrosis of the Femoral Head

BackgroundWhether artificial bone provides comparable outcomes to autogenous bone has not been determined for osteonecrosis of the femoral head (ONFH). This study was conducted to compare the clinical outcomes of autogenous and artificial bone grafting (demineralized bone matrix/calcium sulfate [DBM/CaS]) through a modified lightbulb technique by percutaneous femoral neck-head fenestration for treating precollapse ONFH. MethodsA total of 73 Association Research Circulation Osseous Stage Ⅱ ONFH patients (81 hips) who had a mean follow-up of 61 months (range, 52 to 74) were included in this retrospective study. Among them were 40 hips treated with autogenous bone and 41 hips treated with DBM/CaS grafting through the percutaneous femoral neck-head fenestration. The Harris scores, radiographic progressions, clinical success rates, and survival analyses were analyzed. ResultsAt final follow-up, the mean Harris score was 80 points (range, 63 to 92) in the DBM/CaS group and 76 points (range, 69 to 91) in the autogenous bone group (P = .751). The radiographic progression rate was 29.9% in the DBM/CaS group, without significant difference from the autogenous bone group, which was 37.5% (P = .43). About 73.2% of patients in the DBM/CaS group and 75% in the autologous bone group avoided a total hip arthroplasty (P = .85). Survival analysis for femoral head protection revealed similar outcomes between the 2 groups (P > .05). ConclusionPercutaneous femoral neck-head fenestration combined with artificial bone (DBM/CaS) grafting had comparable clinical outcomes to autologous bone grafting on preventing femoral head collapse and rescuing THA at a mean of 61-month follow-up for treating early ONFH.

Evaluation of the predictive values of collapse and necrotic lesion boundary for osteonecrosis of the femoral head prognosis.

Osteonecrosis of the femoral head (ONFH) is a disabling and intractable orthopedic disease largely affecting young and middle-aged groups. Current standard of treatment relies on the collapse of femoral head as a predictor for prognosis. However, a wide range of variability in repair potentials is observed in patients with femoral head collapse. Therefore, the present study aimed to evaluate the accuracy of femoral head collapse as a predictor and to propose the necrotic lesion boundary as a novel yet reliable measure for ONFH prognosis. A retrospective cross-sectional study was conducted at the First Affiliated Hospital of Guangzhou University of Chinese Medicine, 203 hips with ONFH from 134 patients were included. The occurrences and progression of femoral head collapse were recorded. Necrosis lesion boundary was quantified and classified for each case based on anteroposterior view intact ratio (APIR) and the frog-leg view intact ratio (FLIR) as independent variables. Dependent variables were defined as progressive collapse or terminal collapse for Association Research Circulation Osseous (ARCO) stage II and III respectively. Logistic regression analysis, Receiver Operating Characteristic (ROC) curve and Kaplan-Meier (K-M) survival analysis was performed and results were interpreted. Out of the 106 hips in ARCO stage II, 31 hips collapsed with further progression, while 75 hips had no collapse or collapse with repair of the necrotic areas. Out of the 97 hips in ARCO stage IIIA, the collapse continued to progress in 58 hips while the necrotic areas were repaired in 39 hips. Logistic regression analysis demonstrated that both APIR and FLIR, were independent risk factors. Further ROC curve analysis indicated that the cutoff values of APIR and FLIR could be considered as indications for evaluating the prognosis of ONFH. Contrary to the traditional view of poor prognosis after femoral head collapse, K-M survival analysis demonstrated a high value of APIR and FLIR for ONFH prognosis. The present study found that the occurrence of collapse is an oversimplified predictor for ONFH prognosis. The collapse of the femoral head in ONFH does not predict a poor prognosis. The necrosis lesion boundary has a high value in predicting ONFH prognosis and informing clinical treatment strategies.

Detection of Subchondral Bone Microcirculatory Perfusion in Adults with Early Osteonecrosis of the Femoral Head Using Contrast-Enhanced Ultrasound: A Prospective Study.

The aim of this study was to quantitatively assess subchondral bone microcirculation perfusion in adults with early osteonecrosis of the femoral head (ONFH) using contrast-enhanced ultrasound (CEUS) and to evaluate its correlation with the Association Research Circulation Osseous (ARCO) stage. We investigated 97 adult patients with definite ONFH by imaging a total of 155 hips, performing CEUS, storing images of CEUS processes at different ARCO stages and generating CEUS time-intensity curves (TICs) to obtain perfusion parameters. Differences in CEUS parameters at different ARCO stages were analyzed, and correlations were explored. A logistic regression model was constructed by incorporating the meaningful CEUS indicators. The CEUS parameters time to peak (TTP), peak intensity (PI), enhanced intensity (EI), ascending slope (AS), descending slope (DS) and area under the receiver operating characteristic curve (AUC) were significantly different in ARCO stage Ⅰ compared with stage ⅢA, and the same results were obtained in stage Ⅱ compared with stage ⅢA. However, there were no significant differences between stages Ⅰ and Ⅱ. The MTT (mean transit time) assay was not significantly different between the different stages. The receiver operating characteristic curve analysis of TTP, PI, EI, AS, DS and AUC in stages Ⅰ and ⅢA had a certain diagnostic efficacy, similar to the results in stages Ⅱ and ⅢA. The diagnostic performance of DS was less accurate in stages Ⅰ and ⅢA, while the diagnostic performance of TTP was less accurate in stages Ⅱ and ⅢA. ARCO stage was independently and negatively correlated with TTP and DS and independently and positively correlated with PI, EI, AS and AUC. The MTT assay was not correlated with ARCO stage. Logistic regression models containing statistically significant TTP, EI and AUC values were constructed, and all three values were closely related to the ARCO stage. In patients with different ARCO stages of ONFH, CEUS can effectively assess subchondral bone perfusion of the femoral head and is expected to become an effective imaging method for the diagnosis of early ONFH.

Quantitative analysis of local microcirculation changes in early osteonecrosis of femoral head: DCE-MRI findings.

This study aims to quantitatively analyze the changes in local microcirculation in early osteonecrosis of the femoral head (ONFH) by dynamic contrast-enhanced (DCE) MRI and to explore the pathophysiological mechanisms of early ONFH. We selected 49 patients (98 hips) aged 21-59years who were clinically diagnosed with early ONFH. A total of 77 femoral heads were diagnosed with different degrees of necrosis according to the Association Research Circulation Osseous (ARCO) staging system, and 21 femoral heads were judged to be completely healthy. All patients underwent DCE-MRI scanning. Pseudocolor images and time-signal intensity curves were generated by Tissue 4D processing software. The volume transfer constant (K trans), extracellular extravascular space, also known as vascular leakage (V e), and transfer rate constant (K ep) of healthy and different areas of necrotic femoral heads were measured on perfusion parameter maps. The differences and characteristics of these parameters in healthy and different areas of necrotic femoral heads were analyzed. The signal accumulation in healthy femoral heads is lower than that of necrotic femoral heads in pseudocolor images. The time-signal intensity curve of healthy femoral heads is along the horizontal direction, while they all have upward trends for different areas of necrotic femoral heads. The mean value of K trans of healthy femoral heads was lower than the integration of necrotic, boundary, and other areas (F = 3.133, P = .036). The K ep value of healthy femoral heads was higher than the integration of lesion areas (F = 6.273, P = .001). The mean V e value of healthy femoral heads was smaller than that of the lesion areas (F = 3.872, P = .016). The comparisons of parameters between different areas and comparisons among healthy areas and lesion areas showed different results. ONFH is a complex ischemic lesion caused by changes in local microcirculation. It mainly manifests as increased permeability of the vascular wall, blood stasis in the posterior circulation, high intraosseous pressure in the femoral head, and decreased arterial blood flow. The application of DCE-MRI scanning to quantitatively analyze the visual manifestations of microcirculation after early ONFH is an ideal method to study the microcirculation changes of necrotic femoral heads.

Application of artificial intelligence preoperative planning system in total hip arthroplasty for adult developmental dysplasia of the hip

By comparing with the traditional X-ray template measurement method, to explore the accuracy of artificial intelligence preoperative planning system (AI-HIP) to predict the type of prosthesis and guide the placement of prosthesis before total hip arthroplasty (THA) in adult patients with developmental dysplasia of the hip (DDH). Patients with DDH scheduled for initial THA between August 2020 and August 2022 were enrolled as study object, of which 28 cases (28 hips) met the selection criteria were enrolled in the study. Among them, there were 10 males and 18 females, aged from 34 to 77 years, with an average of 59.3 years. There were 12 cases of the left DDH and 16 cases of the right DDH. According to DDH classification, there were 10 cases of Crowe type Ⅰ, 8 cases of type Ⅱ, 5 cases of type Ⅲ, and 5 cases of type Ⅳ. According to Association Research Circulation Osseous (ARCO) staging of osteonecrosis of the femoral head, 13 cases were in stage Ⅲ and 15 cases in stage Ⅳ. The disease duration was 2.5-23.0 years (mean, 8.6 years). The limb length discrepancy (LLD) was 11.0 (8.0, 17.5) mm. Before operation, the prosthesis types of all patients were predicted by AI-HIP system and X-ray template measurement method, respectively. And the preoperative results were compared with the actual prosthesis type during operation in order to estimate the accuracy of the AI-HIP system. Then, the differences in the acetabular abduction angle, acetabular anteversion angle, femoral neck osteotomy position, tip-shoulder distance, and LLD were compared between preoperative planned measurements by AI-HIP system and actual measurement results after operation, in order to investigate the ability of AI-HIP system to evaluate the placement position of prosthesis. The types of acetabular and femoral prostheses predicted based on AI-HIP system before operation were consistent with the actual prostheses in 23 cases (82.1%) and 24 cases (85.7%), respectively. The types of acetabular and femoral prostheses predicted based on X-ray template measurement before operation were consistent with the actual prostheses in 16 cases (57.1%) and 17 cases (60.7%), respectively. There were significant differences between AI-HIP system and X-ray template measurement (P<0.05). There was no significant difference in acetabular abduction angle, acetabular anteversion angle, femoral neck osteotomy position, and tip-shoulder distance between AI-HIP system and actual measurement after operation (P>0.05). LLD after operation was significantly lower than that before operation (P<0.05). There was no significant difference between the LLD predicted based on AI-HIP system and the actual measurement after operation (P>0.05). Compared with the traditional X-ray template measurement method, the preoperative planning of AI-HIP system has better accuracy and repeatability in predicting the prosthesis type. It has a certain reference for the prosthesis placement of adult DDH.