Avascular Necrosis In Patients Research Articles

E030 Osteonecrosis of the spine in antiphospholipid antibody syndrome

Abstract Background/Aims Osteonecrosis (ON) is a well-known complication of several rheumatic diseases, affecting the hip, knee, shoulder, or ankle. The involvement of spine and other sites with ON has been reported with catastrophic APS, although the nature of this association is not completely clear. In antiphospholipid syndrome, thrombosis of blood vessels is considered a possible mechanism, along with other risk factors, such as active disease, thrombocytopenia, glucocorticoid use and associated autoimmune diseases, making the pathophysiology multifactorial. We report a case of a 66-year-old male with APS who developed bone infarcts/osteonecrosis after withdrawal of anticoagulation for APS, which was necessitated by a bleeding complication and introduction of steroids for immune thrombocytopenia. Methods A 66-year-old male came to us with history of unprovoked deep vein thrombosis (DVT) for which he was on antiplatelet and anticoagulation for over 20 years. He was diagnosed to have high titre anti cardiolipin antibody (ACA)(186 U/ml) without other autoimmune conditions. He had an episode of bladder hematoma in August 2022, needing his anticoagulation to be suspended temporarily. He was also found to have profound thrombocytopenia with raised inflammatory markers. Considering it to be immune mediated he was started on high dose oral corticosteroids and was later maintained with azathioprine while the oral prednisolone dose was gradually brought down to 10 mg daily in about 3 months’ time. His thrombocytopenia improved progressively however he developed an unprovoked DVT in October 2022 and was restarted on anticoagulation. He continued to have low dose steroids for about 6 months. Meanwhile, he started having a new onset of low back pain in December 2022. An MRI of the whole spine showed multilevel osteonecrosis with haemorrhagic cavities in a few vertebral bodies. Results This case highlights three interesting points. The first is the atypical presentation of the osteonecrosis involving vertebral bodies. Osteonecrotic lesions in the spine of a patient with catastrophic primary antiphospholipid syndrome has been reported. Our case signifies that although vertebral bodies are an uncommon site for avascular necrosis in patients with APS, it is not rare. Secondly, the pathogenesis of ON is complex. Whether ACA are directly responsible for this condition or whether they are the bystanders remains controversial. ACA have shown to be an independent risk factor for developing ON in many studies. Thirdly, steroids are known to be an important risk factor in patients presenting with osteonecrosis. The vascular compromise could be attributed to a steroid induced hypercoagulative state, abnormal lipid metabolism, or fat embolism. Conclusion ON in APS is unusual and its underlying pathophysiology remains multifactorial. However, when complicated by the high ACA levels, active disease, difficult anticoagulation (bleeding tendencies), thrombocytopenia or prolonged use of steroids, it can lead to hypercoagulable state causing micro thrombosis and avascularisation. Disclosure M. Shah: None. K. Putchakayala: None.

Incidence of avascular necrosis of native femur following hip transposition surgery for periacetabular malignancies: a single-centre experience.

Hip transposition surgery after surgical resection of large pelvic tumours is a well-established alternate to endoprosthetic reconstruction. The major goals of surgery are to ensure adequate resection margins with limb salvation, albeit with acceptable levels of morbidity. While surveillance is aimed at diagnosing local recurrence or distant metastasis primarily, other complications may occasionally be seen.The aim of this study was to assess incidence of avascular necrosis (AVN) in the preserved native femoral heads after hip transposition surgery for periacetabular malignancies, also known as hanging hip surgery. Patient records and follow-up imaging of 22 patients who had undergone hanging hip surgery from 1999 to 2020 were retrospectively analysed to assess for any probable causes of AVN. Of the 22 patients, 5 (22.7%) had developed AVN on follow-up with a mean time of onset of about 10.5 months from surgery (5 months-2 years). A review of the patient demographics, surgical notes, preoperative management did not offer any clues as to the cause of AVN in these patients. Osteopenia was the most common radiological finding (59%) in most patients, but this also did not herald AVN onset. The theory that loss of major vascular supply to the femoral head from capsular disruption during hip transposition surgery would lead to AVN in most patients did not hold true as AVN occurred in a small number of patients.

Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

Introduction/Purpose: Avascular necrosis (AVN) is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is considered to be a strong predictor of preserved talus vascularity. The study sought to assess the accuracy of the Hawkins sign in a large, contemporary cohort and assess factors associated with inaccuracy. Methods: A retrospective review of all talar neck fractures from a single level I trauma center from 2008 to 2016 was performed. The presence of Hawkins sign and AVN were determined based on ankle radiographs 8 weeks after injury and at final follow-up, respectively. Patients with less than 6 months follow-up were excluded. Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (C.I.) and associations were examined with Fisher’s exact testing. Results: In total, 137 talar neck fractures were identified with 105 having adequate follow-up. Hawkins sign was observed in 21 tali, 3 (14%) of which later developed AVN (95% C.I., 3 – 36%). In the remaining 84 tali without Hawkins sign, 32 (38%) developed AVN (95% C.I., 28 – 49%). Of the 3 tali that developed AVN following observation of Hawkins sign, all patients were smokers. There were no cases of AVN in non-smokers with Hawkins sign (P=0.21), and smoking was not associated with AVN in patients without Hawkins sign (41% vs 36%, P=0.82). Conclusion: Hawkins sign may not be a reliable predictor of preserved talus vascularity in all patients. We identified three patients with positive Hawkins signs who developed AVN, all of whom were smokers. Factors impairing microvascular blood supply to the talus may lead to AVN even in the presence of preserved macrovascular blood flow and an observed Hawkins sign. Close monitoring of select patients with Hawkins sign should be considered and further research is needed to understand the factors limiting Hawkins sign accuracy. Prognostic accuracy of the Hawkins sign in predicting talar AVN

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis.

To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). Retrospective cohort. Single level I trauma center. Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Comparative Analysis of Osteochondritis Dissecans and Avascular Necrosis: A Comprehensive Review.

Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients' quality of life with pain, limited mobility, and dysfunction. OCD, involving cartilage and bone detachment in joints, predominantly affects young athletes, but its exact etiology and optimal management remain subjects of ongoing research. Conversely, AVN, marked by bone tissue death due to compromised blood supply, is linked to systemic factors like corticosteroid use and traumatic injuries. Diagnosis for both conditions relies on radiography and magnetic resonance imaging. Conservative treatment for AVN includes the use of a cane or crutches, pharmacological therapy, or physical therapy. On the other hand, in OCD, the primary approach is activity/sports restriction. Surgical treatment options for AVN patients encompass core decompression, bone grafting, or, in the most advanced cases, total hip arthroplasty. OCD may be surgically treated through subchondral drilling or fixation of unstable lesions. Advanced cases of OCD involve cartilage salvage with resurfacing techniques. The presentation of differences between these conditions enhances our understanding, facilitating improved diagnosis and management strategies.

Vitamin D Deficiency and Avascular Necrosis in Patients with Sickle Cell Disease: A Retrospective Cohort Study

Introduction Sickle cell disease (SCD) is an inherited hemoglobinopathy with complex systemic involvement. Avascular necrosis (AVN) is a devastating complication among patients with SCD. Vitamin D deficiency (VDD) is commonly found in SCD patients, but there is limited research on the potential role of VDD as a risk factor for AVN in SCD patients. This study aimed to assess the association between VDD and AVN and determine the patterns, risk factors, diagnosis, and treatment of AVN in SCD patients. Methods We conducted a retrospective cohort study of consecutive SCD patients diagnosed with VDD from January 2020 to December 2022 at Prince Sultan Medical Military City (PSMMC) in Riyadh, Saudi Arabia. Patients meeting the following criteria were included: (1) adults and children with confirmed SCD through hemoglobin electrophoresis and (2) tested for VDD. Patients who underwent bone marrow transplant were excluded. The main outcome measured was the occurrence of AVN. VDD was diagnosed in patients with 25-hydroxyvitamin D levels below 30 nmol/L. Magnetic resonance imaging was used to stage and confirm AVN diagnosis. Associations were assessed using the chi-square test, and logistic regression was performed to control for confounding. Results The study included 711 eligible SCD patients, with 271 (38%) being children. VDD affected 301 out of 711 patients (42.3%). Among these, 212 (70.4%) were adults (>18 years old). VDD was observed in 32.2% of children and 48.1% of adults. Of the total cohort, 127 (17.9%) patients experienced AVN, including 18 children. Among patients with VDD, 89 developed AVN, while VDD affected 212 patients without AVN. The time between VDD diagnosis and AVN presentation ranged from 3 to 12 months. Male patients accounted for 52% of AVN cases. The average age at AVN diagnosis was 30.9 ± 11 years. The most common clinical presentation of AVN was chronic joint pain in over 95% of patients. Other presentations included limping in 3.9% of patients and limited joint movement in one patient. Affected joints included the hip (86%), shoulder (16.5%), knee (4.7%), and sacroiliac joint (0.7%). Bilateral joint involvement was present in 50.4% of AVN patients. The majority of patients (76.4%) were diagnosed with advanced stage AVN (III/IV). Treatment of patients with AVN included joint replacement in 44 (34.6%) patients, while the remaining 83 patients managed with conservative therapy such as pain control and physiotherapy. Patients with a history of VDD were significantly associated with a higher risk of AVN (p < 0.001), as seen in Table 1. Multivariate logistic regression showed SCD patients with VDD had 9.79 times the odds of AVN compared to SCD patients without VDD (OR 9.79; 95% CI: 5.25-18.26). Other statistically significant risk factors for AVN included frequent vaso-occlusive crises (three or more episodes per year), older age, history of acute chest syndrome, and low hemoglobin F levels. Conclusion AVN is a significant cause of morbidity in our SCD cohort, with most patients having advanced AVN disease. VDD is an independent risk factor for AVN in patients with SCD. Well-designed randomized trials are needed to determine the effect of vitamin D supplementation in reducing AVN in children and adults with SCD.

Twenty-Three-Year-Old Collegiate Soccer Athlete With Bilateral Femoral Head Avascular Necrosis: A Case Report

A 23-year-old collegiate club soccer player reported to his athletic trainer right hip flexor pain and no recalled mechanism. Diagnostic imaging revealed bilateral avascular necrosis (AVN) of both femoral heads. Medical intervention included bilateral core decompression surgery. The majority of reported AVN cases are pediatric patients and adults over 50 years old, following trauma (i.e., femoral fracture) being the main risk factor. Although not seen often in athletic populations, athletic trainers should be aware of the possibility of AVN in patients. AVN is a life-altering condition and accurately documenting all patient encounters, and proper interprofessional collaboration is imperative for positive outcomes.

Effectiveness of Platelet-Rich Plasma as an Adjunct to Core Decompression to Treatment Outcomes and Femoral Head Preservation in Avascular Necrosis of the Hip: A Meta-Analysis of Randomized Controlled Trials

Background: Avascular necrosis (AVN) of the femoral head results from intraosseous pathology causing functional impairment. Early diagnosis allows conservative treatment like core decompression, delaying total hip arthroplasty. Objective: This meta-analysis aims to summarize platelet-rich plasma's (PRP) impact as an adjunct to core decompression (CD) on treatment outcomes and femoral head preservation in hip AVN. Methods: The study conducted a comprehensive literature search using PubMed, Cochrane Library, Science Direct, Google Scholar and Med Line, including randomized controlled trials (RCTs) and previous meta-analyses from various databases. Using a random effects model, it compared PRP+CD with bone grafting to CD with bone grafting alone in AVN patients, evaluating function, pain scores, disease progression and the need for hip surgery. Results: The meta-analysis examined 1041 records and included three studies. The primary outcomes were function and pain scores using Harris Hip Scoring (HHS) and Visual Analog Scale (VAS). Postoperative HHS scores at final follow-up favored the PRP+CD group significantly over CD alone. Postoperative VAS scores showed a trend towards higher scores in the CD alone group. The PRP+CD group demonstrated higher survival from disease progression compared to CD alone. Overall, the study suggests that PRP+CD led to better functional outcomes and disease progression outcomes than CD alone in AVN of the hip. Conclusion: The PRP+CD treatment group showed significant benefits in AVN patients compared to CD alone, including higher HHS scores, improved disease progression survival and reduced need for hip surgery. Although PRP+CD resulted in decreased VAS scores, the difference was not statistically significant. Keywords : Avascular Necrosis/AVN, Osteonecrosis, Femoral Head, Platelet-Rich Plasma, Core Decompression and Randomized Controlled Trial

Clinical and epidemiological features and therapeutic options of avascular necrosis in patients with sickle cell disease (SCD): a cross-sectional study.

Avascular necrosis (AVN) is a debilitating complication in sickle cell disease (SCD) patients, and its management is usually challenging. This study aims to evaluate the clinical and epidemiological features and therapeutic options of AVN in sickle cell patients in Qatar. A cross-sectional study was conducted on a 49 SCD patients who were diagnosed with AVN and attended the hematology clinic at the National Center for Cancer care & research, Hamad Medical Corporation, Qatar between Jan-2011 to Jan2021. Results: Forty-nine adult patients with SCD who were diagnosed with AVN were studied. The median age of the study population is 32 years, and the median age at the first AVN diagnosis was 26 years (range: 11-44 yr.). 37 (75.5%) patients suffered from multiple joints AVN while 12(24.5%) had single joint involvement. 31 (63.3%) patients had bilateral hip AVN and 18 (36.7%) had shoulder involvement. 30 patients (61%) were on Hydroxyurea treatment. Based on FICAT and Alert classification of AVN, 57 % of patients had stage III and above at first diagnosis. 20 (40.8%) were managed with a conservative approach, 11 (22.4%) received hyperbaric oxygen with good response, 6(12.2%) underwent hip core decompression and 12(24.5%) underwent hip replacement surgery. In SCD patients, AVN occurred more during the 3rd and 4th decades of life. The majority of AVN represented with advanced stage and had multiple joint involvements. We recommend adopting a low threshold of joint imaging for early detection and prevention of further complications.

Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk.

Avascular necrosis (AVN) of the humeral head is a relatively frequent complication after proximal humerus fractures (PHF). There are many factors related to the risk of developing AVN, with fracture complexity being one of the most relevant. Aim of the present study is to evaluate the correlation between different classification systems and the risk of post-operative AVN in patients treated with locking plate fixation for Neer 3 and 4-part PHFs. The study population included 44 patients (F:M 2:1, mean age 62) treated between December 2014 and April 2019. Fractures were classified according to Neer, Russo and Lego classifications and Hertel's criteria. AVN was established on postoperative radiographs after a minimum follow-up of 6 months. The odds ratio (OR) for AVN for each classification subtype was calculated. The incidence of necrosis was 11%. Significant association with AVN was found for Neer 4 part (OR=8), Russo IVB (OR=4), Lego pattern 12 (OR=8) and in presence of 3 mayor Hertel's criteria (OR=15,5). There is a significant association between AVN and Neer 4 part, Russo type IVB and Lego pattern 12 fractures. AVN risk is also significantly higher in presence of 3 major Hertel's criteria.

Risk factors for avascular necrosis in patients with systemic lupus erythematosus: a multi-center cohort study of Chinese SLE Treatment and Research Group (CSTAR) Registry XXII

BackgroundAvascular necrosis is a common organ damage in SLE patients, which can influence patients’ life quality. Conflicting results exist in risk factors of AVN in SLE patients. The aim of this study was to illustrate risk factors predicting the occurrence of avascular necrosis (AVN), also known as osteonecrosis, in systemic lupus erythematosus (SLE) patients in Chinese SLE Treatment and Research Group (CSTAR), a multi-center cohort of Chinese SLE patients.MethodsSLE patients in CSTAR without existing AVN at registration were included. At least two follow-ups and an observation period of no less than 2 years for AVN event were required. Univariate and multivariate Cox regression analyses were used to evaluate risk factors for AVN in SLE patients. Coefficient B was transformed to risk score for the development of a risk stratification model.ResultsOne hundred six (2.59%) of 4091 SLE patients were diagnosed AVN during follow-ups of no less than 2 years. Multi-variate Cox regression analysis suggested that SLE onset age ≤ 30 (HR 1.616, p 0.023), arthritis (HR 1.642, p 0.018), existing organ damage (SDI ≥ 1) at registration (HR 2.610, p < 0.001), positive anti-RNP (HR 1.709, p 0.006), and high glucocorticoid maximum daily dose at registration (HR 1.747, p 0.02) were independent risk factors. A risk stratification system was developed according to the risk factors, and patients were divided into high risk (3–6) and low risk (0–2). The AUC of 0.692 indicated moderate discrimination. The calibration curve in internal validation was drawn.ConclusionPatients with SLE onset age ≤ 30, arthritis, existing organ damage (SDI ≥ 1) at registration, positive anti-RNP, and high glucocorticoid maximum daily dose at registration are at high risk for AVN and require attention.

The incidence, risk factors, and outcomes of symptomatic avascular necrosis of bone among Chinese pediatric patients with acute lymphoblastic leukemia

Avascular necrosis (AVN) of bone is a debilitating complication of pediatric patients with acute lymphoblastic leukemia (ALL). While it is extensively studied and reported in Western population, studies focused on Orientals are limited. This study aims to evaluate the incidence, risk factors, and clinical outcomes of AVN among Chinese children with ALL. This study is a retrospective, territory-wide population-based cohort study of pediatric patients with ALL enrolled on one of the three consecutive ALL study protocols (ALL-IC-BFM 2002, CCLG-ALL 2008, and CCCG-ALL 2015). A total of 24 out of 533 pediatric subjects with ALL (4.5%) had symptomatic AVN. Age was the single most important risk factor associated with the development of AVN. Only three patients were below age of 10 at the time of diagnosis of ALL. The incidences of AVN in patients aged above and below 10 years were 18.2% ± 3.6% and 0.8% ± 0.5%, respectively, and were significantly different (p < 0.005). Treatment protocol, immunophenotype, and gender were not predictive of AVN. Among the 24 patients, five required orthopedic interventions in view of progressive and severe disease. For subjects with hip joints involvement, follow-up assessments showed 12 of 22 hip joints had radiological progression over a median duration of 3.63 years. Seventeen of them did not have pain at the latest follow-up and among patients with pain (n=7), five did not experience any limitation on activities of daily living while two required use of walking aids or wheelchair. The incidence of symptomatic AVN in Chinese ALL patients was comparable to other studies in Western population. Adolescent age more than 10 years old was recognized to be the most important factor for development of AVN. Significant proportion of patients had radiological progression over time with a small percentage of subjects had daily activities affected.

Impact of sickle cell disease in shoulder arthroplasty: a matched cohort analysis.

Sickle cell disease (SCD) is a genetic disorder of abnormal hemoglobin synthesis that is known to cause glenohumeral avascular necrosis (AVN). Little has been published on the use of shoulder arthroplasty (SA) for the treatment of glenohumeral AVN in SCD. We report on the clinical and radiographic results and postoperative complications following SA in the patient cohort. A retrospective review was performed identifying 17 primary SAs (9 hemiarthroplasties, 7 anatomic total SAs, and 1 reverse total SA) in patients with a confirmed diagnosis of SCD and a minimum of 2-year follow-up. This cohort was matched (1:2) according to age, sex, body mass index, type of prosthesis, and year of surgery with patients who had undergone hemiarthroplasty or total SA for osteoarthritis (OA) or reverse total SA for cuff tear arthropathy. Outcomes included the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons score, range of motion, and strength measurements in forward elevation (FE), external rotation (ER), and internal rotation (IR). Our cohort included 9 (52.9%) men with a mean age of 43yr. The average follow-up time was 5.9yr. In patients with SCD, SA provided significant improvements in VAS pain (9.1-3.8; P<.001), FE (95°-128°; P<.001), ER (24°-38°; P<.001), IR score (3.2-5.2; P<.001), FE strength (4.2-4.8; P<.001), ER strength (4.1-4.7; P<.001), IR strength (4.1-4.7; P<.001), and American Shoulder and Elbow Surgeons scores (48.6-73.5; P<.001). When compared to the matched cohort, the SCD group demonstrated higher preoperative (9.1 vs. 3.8; P<.001) and postoperative VAS scores (3.8 vs. 1.3; P<.001). Other clinical outcomes demonstrated no significant differences. There were 5 (29%) complications, 2 (11.8%) episodes of sickle cell crisis, and 3 (18%) reoperations in the SCD cohort. When compared to the matched cohort, there were no statistical differences with respect to complications (29% vs. 12%; P=.140) or reoperations (18% vs. 12%; P=.387). SA is an effective treatment modality for glenohumeral AVN in patients with SCD. Patients may expect improvements in pain, function, motion, and strength. However, final postoperative pain relief may be less than those treated with SA without SCD. Unique perioperative management is necessary to mitigate the risk of postoperative sickle cell crises.

P838 Increased Risk of Avascular Necrosis in Patients With Inflammatory Bowel Disease: a nationwide population based cohort study

Abstract Background Avascular necrosis (AVN) is bone death due to disruption of blood supply causing disability and significant morbidity. Although considered multi-factorial, corticosteroid use is a well-known risk factor. Not only is AVN more prevalent in Inflammatory bowel disease (IBD), but IBD patients are often exposed to higher corticosteroids usage. Therefore, we aimed to investigate epidemiology and risk factors of avascular necrosis in Asian IBD patients. Methods We conducted a nationwide population-based cohort using Korean National Health Insurance Service (NHIS) database from January 2007 to December 2020. Newly diagnosed IBD patients were defined according to the International Classification of Diseases, 10th revision (ICD-10), and at least one prescription of IBD-specific medications. 1:3 sex-, age- matched subjects from the general population were selected. We investigated newly diagnosed AVN using the ICD-10 code and the incidence rates and risk of AVN were assessed with multivariate cox regression models. Results A total of 62,417 IBD population was identified, where ulcerative colitis (UC) comprised of 44,106. Age at diagnosis was younger in Crohn's disease (CD) than in UC (30±15 years and 43±16.3 years). UC population revealed greater number of comorbidities such as hypertension (16.7% and 7.1% for UC and CD, respectively), diabetes mellitus (12.4% and 9.5%), dyslipidemia (27.6% and 25.2%), and cerebrovascular diseases (4.5% and 2.5%). During the mean follow-up period of 6.75 years, 54,591 (87.5%) of the total IBD patients were exposed to systemic steroids (86.4% and 90.1% for UC and CD, respectively). Approximately 76.8% in the IBD group were prescribed with ≥10 mg/day of corticosteroids with mean duration of 16.3±35.1 days. A total of 100 (0.16%) newly diagnosed AVN cases were observed in the IBD population. Time from the index date to AVN diagnosis was 4.47±3.29 years. Compared to the non-IBD controls, the incidence of AVN was significantly increased in IBD subjects (adjusted hazard ratio [aHR] with 95% confidence interval [CI], 1.28 [1.01-1.63]). UC patients in particular were at an elevated risk for developing AVN (aHR with 95% CI, 1.39 [1.07-1.80]), whereas risk analysis for CD patients demonstrated results that were statistically not significant (aHR with 95% CI, 1.00 [0.63-1.57]). Table 1 Incidence rates and risk ratios of AVN in patients with IBD Conclusion Risk of AVN was elevated in Korean IBD patients compared to non-IBD population, especially for UC. Physicians dealing with IBD patients should be aware of etiological factors of AVN along with corticosteroid use. Future study is needed to investigate on the mechanisms associated with AVN in IBD.

Total Hip Arthroplasty via direct anterior approach for osteonecrosis; comparison with primary hip osteoarthritis in a mid term follow up

BackgroundTo determine the mid-term outcomes of conventional cementless Total Hip Arthroplasty (THA) in patients with avascular necrosis (AVN) of the femoral head and compare to patients with primary hip osteoarthritis (OA). MethodA total of 330 consecutive primary THA procedures (AVN and OA) performed between 2010 and 2013 by a single surgeon and in a single center using the direct anterior approach (DAA) were included. Assessments including SF-36, WOMAC, and Harris Hip Scores (HHS) were retrieved from patients before the surgery and at the latest follow-up. Clinical and functional outcomes were compared between the AVN and OA groups. ResultsA total of 294 consecutive THA (AVN = 107, OA = 187) with 104.4 ± 6.2 months follow-up were analyzed, which AVN patients were significantly younger (32.0 vs. 59.6 y/o). Corticosteroid 34 (31.8%), idiopathic AVN 31 (29.0%) and use of unapproved weight gain supplements (UWGS) 23 (21.5%) were the main reasons for AVN. Despite that preoperative scores were comparable (P > 0.05), the HHS, SF-36, and WOMAC scores are significantly higher in the AVN group after THA surgery (P < 0.05). Moreover, flexion and abduction ROM were significantly higher in the AVN group (P < 0.05). Regarding each complication, no significant difference was observed between groups. In the whole sample, there were 5 (1.7%) revisions due to loosening of acetabular components, all the OA group (P > 0.05). ConclusionConventional cementless THA with highly cross-linked polyethylene provides satisfactory mid-term results in patients with AVN with a low rate of postoperative complications. Compared to primary OA patients, this group reaches superior postoperative scores.

Outcome analysis of bilateral total hip replacement in patients of avascular necrosis of femoral head

Avascular necrosis (AVN) of the femoral head is one of the common causes of painful hip in a young adult. Bilateral presentation is frequently seen and males are more commonly affected. Total hip replacement (THR) is one of the most successful surgical procedures for AVN. THR is a time tested surgery giving good outcome in terms of relieving pain, restoring function &amp; improving quality of life in patients of AVN. The purpose of the study was to analyse the outcome of bilateral THR &amp; comparing the outcome of one stage THR with Two stage THR. In this study, 40 patients with AVN of bilateral femoral head who were presented in the Department of Orthopaedics, Hamidia Hospital, Bhopal from April 2016 to April 2020 who fulfilled the inclusion criteria were included in the study. THR of all the patients was done on elective basis by senior surgeons of the department. All patients were followed up clinically and radiologically for a period of 6 months after the surgery. Any complications if present were also noted. This study concludes that in patients of AVN of bilateral femoral head, THR gives excellent functional outcome with early walking &amp; early return to work. As compared to Two stage bilateral THR, One stage bilateral THR has advantage of less blood loss, less need of parenteral analgesics &amp; antibiotics &amp; less hospital stay. However, there is no significant advantage in terms of functional outcome, walking capability &amp; return to work.

Comparison of clinical outcomes of autologous bone graft versus pronator quadratus pedicled vascularized bone graft in the treatment of scaphoid nonunion.

We aimed to compare the union rate and clinical outcome of autologous bone graft versus pronator quadratus vascularized pedicled muscle flap in treatment of scaphoid nonunion. Forty patients with a diagnosis of scaphoid nonunion who underwent unilateral pseudarthrosis surgery were included in this study. Notably, the scaphoid nonunion was unilateral, and the contralateral wrist was asymptomatic with normal function, per the physical and radiological examinations. Pronator quadratus vascularized pedicled muscle flap was used in 16 patients (group 1), and autologous bone graft was used in 24 patients (group 2). Patients were compared used Scapholunate angles, Natrass carpal height ratio and Mayo wrist score pre and postoperatively. Fifteen of the 16 (93.3%) patients in group 1 and 19 of the 24 (79.2%) patients in group 2 achieved bone union. Four of twelve patients in group 2 with avascular necrosis (AVN) and one of eight in group 1 with AVN were not able to achieve union. The group 2 (34%) had higher nonunion rate than group 1 (12%) in AVN patients. The scapholunat angle was significantly decreased and the Natress ratio was significantly increased postoperatively compared to the preoperative measurement in both group. There was no statistically significant difference in the postoperative measurement. The postoperative Mayo wrist score showed no statistically significant differences between both groups. The pronator quadratus vascularized pedicled muscle flap was superior to non-vascularized bone grafting in the treatment of scaphoid nonunion with AVN. However, management of the patients without avascular necrosis is not requiring the vascularized pedicled muscle flap technique.

An early experience of the use of dual mobility cup uncemented total hip arhroplasty in young patients with avascular necrosis of the femoral head

IntroductionTHA (Total hip arthroplasty) in advanced grade (grade 4) avascular necrosis (AVN) is a challenge to the treating surgeon as it affects young patients who have high functional demands and increased dislocation risk. The aim of the study was to evaluate the efficacy, survivorship, and dislocation rate of uncemented dual mobility cups (DMC) in advanced grade IV AVN young patients. MethodsRetrospective cohort study involving 204 DMC THA for advanced grade IV AVN from January 2013 to December 2015. The sample size of the study was estimated to be 188 hips with an α error of 0.05 and β error of 0.2. Inclusion criterion was patients less than 55 years of age with advanced grade IV AVN. Patients >55 years of age, patients diagnosed with primary osteoarthritis of the hip and hip fracture were excluded from the study. 172 patients (32 with bilateral & 140 with unilateral affection) with 204 DMC THA were evaluated clinically by Harris Hip Score (HHS) and radiologically at a follow up of 60 months. P value < 0.05 was considered significant. ResultsMean age of the patients was 42.5 ± 5.3. Preoperative HHS was 50.6 ± 10.5. Postoperative HHS at 5 years follow up was 96.4 ± 2.6. None of the operated patient had any dislocation episode or had undergone hip revision surgery (statistically significant against historical control of 2%, p value = 0.042). The radiological evaluation at 5 years showed no signs of radiolucent lines, periprosthetic osteolysis, polyethylene wear and signs of displacement or migration of the DMC. Cumulative survivorship rate at 5 years follow up was 100% without any revision/dislocation. ConclusionUse of DMC THA in young, advanced grade IV AVN patients was found to be a reliable option showing excellent early functional results with no dislocation. Ongoing follow up of this cohort is required to confirm the maintenance of these excellent functional results at follow up in the long term.

Avascular Necrosis After Modified Dunn Surgery for the Treatment of Slipped Capital Femoral Epiphysis.

Objective The present study analyzed the incidence of epiphyseal avascular necrosis in patients with slipped capital femoral epiphysis (SCFE) treated using a modified Dunn technique. In addition, this study determined the correlation of other variables with this incidence and described treatment complications. Methods This is a retrospective study with 20 patients treated by the same surgical team from 2009 to 2019 and followed up for 2 to 12 years. The analysis included general features, time from presentation to surgical procedure, classification, and intraoperative blood perfusion of the epiphysis, as well as complications and their treatment. Results All cases were severe; 65% were acute on chronic, and 55% of the SCFEs were unstable. Our complication rate was 45%, with 5 cases of avascular necrosis, 2 cases of deep infection, 1 case of material failure, and 1 case of joint instability. The statistical analysis revealed that the risk of necrosis was higher when the surgery occurred after a long hospitalization time and there was no intraoperative epiphyseal perfusion. Four necrosis cases happened within the first 5 years, and 1 case in the last 5 years of the study. Conclusion Our study showed that necrosis was the most common complication. It also revealed that surgery delay and lack of intraoperative epiphysis perfusion potentially predispose to avascular necrosis. Although with no statistical significance, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw. The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible and performed by an experienced, trained, and qualified team.

Concomitant septic arthritis of the hip joint and femoral head avascular necrosis in patients with recent COVID-19 infection: a cautionary report

PurposeAt present, concomitant avascular necrosis (AVN) of femoral head and septic arthritis (SA) as a sequel of COVID-19 infection has yet not been documented. By large-scale use of life-saving corticosteroids (CS) in COVID-19 cases, our aim is to warn of the occurrence of hip joint infection in these patients.MethodsWe report a series of five cases in which patients developed septic arthritis concomitant with AVN after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 1695.2 mg. The time period of onset of hip symptoms in our cases from the beginning of the COVID-19 infection was 56 days in the first case, 43 days in the second case, 30 days in the third case, 29 days in the fourth case and 50 days in the last case, with an average time of 41.6 days. All patients underwent surgery depending on the extent of articular cartilage damage by direct anterior approach.ResultsClinical and laboratory symptoms improved significantly in all patients. The mean visual analogue pain score of the patients decreased from 9.4 (9–10) before surgery to 2.8 (1–4) after 1 week of operation.ConclusionIn any patient with the history of COVID-19 infection specially those who have been treated with corticosteroid as one of the medications prescribed during the disease, any joint symptom specially in the hips should draw our attention to the joint infection, and with timely diagnosis and surgery, their hip joint can be saved.