Avascular Necrosis Of Bone Research Articles

Avascular Necrosis of the Carpal Bones: Etiologies and Treatments

Avascular Necrosis of the Carpal Bones: Etiologies and Treatments

P016: Reduced steroid exposure is safe and does not reduce disease control among Hodgkin Lymphoma patients treated with escalated BEACOPP (eBEACOPP)

Figure 1: PFS (Kaplan-Meier curves): The outcome of EU and AS patients - 5-y PFS 95% vs. 98%, respectively. Full-length vs. shorter steroid courses - 5 y PFS 98% vs. 95%, respectively. Background: eBEACOPP is the most effective chemotherapy regimen for younger patients with early unfavourable (EU) and advanced stage (AS) Hodgkin lymphoma (HL), but is burdened with early and late toxicities. The original 14 days of steroids contributes to side effects, including severe osteoarticular events, like avascular bone necrosis (AVN). We have been using eBEACOPP since 2009 for AS and since 2014 also for EU patients. We started reducing the length of steroid treatment to 8–10 days in 2016, primarily to reduce the risk of AVN. Methods: We analysed outcomes of our patients, focusing on the comparison of EU and AS patients and those receiving full length and shorter steroid courses. Data was obtained retrospectively, from the hospital database. Results: 162 patients received eBEACOPP as front-line treatment, 130 with AS and 32 with EU HL. Median age was 31 y, range 19–59; 88 (54%) were male. After a median follow-up of 58 mo, 5-y PFS of the whole cohort was 97% and OS 98%. The outcome of EU and AS patients was indistinguishable with a 5-y PFS of 95% vs. 98%, respectively (Fig). Outcome of patients receiving full-length or shorter steroid courses was also indistinguishable, with a 5 y PFS of 98% vs. 95% respectively (Fig). The incidence of AVN was numerically, but statistically insignificantly lower in patients receiving 6 cycles of eBEACOPP with a shorter steroid course (1/42 vs. 4/72, p=0.65). There were no differences in emergency hospital admissions and episodes of febrile neutropenia between the two cohorts. Conclusion: eBEACOPP provides excellent and durable first line disease control. Our data confirms the findings of GHSG of lack of outcome differences between different prognostic groups if eBEACOPP is used as primary treatment. Reducing the duration of steroid treatment to 8 days per cycle is safe, but longer follow-up and more patients are needed to confirm that it reduces serious acute and chronic toxicities.

P17 All in the Marrow - A case of Primary Bone Marrow Oedema

Introduction/BackgroundPrimary bone marrow oedema syndrome is an elusive and less well-defined entity. Whether Rheumatologists should consider it as a stand alone diagnosis, is debatable. It possibly would be best described as an MRI feature which could be a finding in a number of diseases which would include the initial phases of Osteonecrosis of the bone, Rheumatoid Arthritis, Spondyloarthritis, Enthesitis related, Post traumatic, OA, Infections and Cancers. The treatment options become constricted due to the paucity of evidence.Rheumatologists need to consider this as an area of unmet need with development of consensus classification criteria and treatment approaches.Description/Method27-year-old male, Height 174 cms Weight 90 Kgs BMI 29 Kg/m2, became symptomatic in Jan 2022 with complains of pain in the both hip joints & groin regions, pain became excruciating and he became bed-bound, with early morning stiffness lasting approximately 45 mins.Had received steroids for COVID infection in August 2020.InvestigationsHb 13.5gm/dl TLC 7000/mm3 Platelet 400 × 103/mm3Sr Bil 0.8mg/dl AST 16 IU/L. ALT 24 IU/L Sr Creatininine 1.1mg/dlBlood Sugar Levels, Fasting 89 mg/dl Post Prandial 102 mg/dlESR 10 mm in 1st hour by Wintrobes method CRP Quantitative 29.38mg/LHLA B27 by PCR Negative, RF Negative, ACCP NegativeSerum, IgG, Beta2 Glycoprotein 1.44 SGU Serum, IgM, Beta2 Glycoprotein 3.44 SGUSerum, IgG, Cardiolipin antibody 8.4 GPL Serum, IgG, Cardiolipin antibody 17.45 GPLLupus anticoagulant by DRVVT NegativeSr Cholesterol 211mg/dl HDL 29 mg/dl LDL 156mg/dl TGs 130 mg/dlMRI Hips & SI joints Transient bone marrow oedema/osteopenia of bilateral hip.PET CT Increased metabolic activity in both hip jointsBone Scan (99mTcMDP) Increased vascularity in perfusion phase, increased accumulation in soft tissue in blood pool phase and increased uptake in bilateral Hip joints in skeletal phase scan, suggestive of CRPS Type-I.ManagementWas initially managed with Tab Etoricoxib 90mg BD, also started on Tab Sulphaslazine and Tab Methotrexate. However, when he had no symptomatic relief he was administered Inj Infliximab on 12 May 2022 and a second dose on 9 June 2022. He had excellent pain relief after the 1st dose, however after 10 days of the administration, he again began experiencing pain especially after walking. He also had pain in the knees on this occasion.He was also administered Inj Zoledronic 4mg on 23 May 2022.He is at present not requiring any NSAIDs over the last 1 month.Discussion/ResultsThe patient having presented with excruciating and debilitating pain was worked up and evaluation revealed features of bone marrow oedema on MRI which was corroborated with bone scan and PET CT imaging. The acute phase reactant CRP was also significantly elevated. The patient also gave history of early morning stiffness lasting approximately 45 mins. Hence an underlying Inflammatory process such as Spondyloarthritis(Peripheral) with enthesitis was considered. The confounding factors were the pain which worsened on mobilization, HLA B27 negative status, Rheumatoid Factor and ACCP negative status and past history of having received IV Corticosteroids for COVID infection in August 2020.In view of the debilitating pain and a working diagnosis of Spondyloarthritis, he was started on NSAIDs along with rest, initially, followed by conventional synthetic disease modifying agents in Rheumatic disease followed by biologic synthetic disease modifying agent – Inj Infliximab.The thought process was to avoid prolonged NSAID use to prevent the associated side effects.However, since Avascular Necrosis of the Femoral head is a very likely possibility, the patient is planned to be kept under close follow up.Key learning points/ConclusionCollaborative efforts between the Departments of Nuclear Medicine, Radiology, Orthopaedics and Rheumatology are crucial in the early detection and approach to cases of Bone Marrow oedema.Avascular necrosis of head of Femur is a far more common entity and must be kept in mind even when a diagnosis of Bone Marrow oedema syndrome is being entertained.Diagnosis of Bone Marrow oedema syndrome must be entertained only as a diagnosis of exclusion.Continued follow up and regular imaging must be pursued rigorously in patients diagnosed with Bone Marrow oedema syndromes.There is a requirement to document acute phase reactants such as CRP and ESR in patients diagnosed with Avascular necrosis of bone as this data could help us differentiate AVN from Primary Bone marrow oedema in the early stages.

Morphometric Study of Nutrient Foramen of Human Tibia Bone in Western Rajasthan Population

Nutrient foramen is an opening, which gives passage to the blood vessels of medullary cavity. In lower limb, the lower end of femur and upper end of tibia are the growing ends. The knowledge of nutrient foramen and nutrient artery is of utmost important in surgical procedures like bone grafting, fracture fixation etc. Damage to nutrient artery causes avascular necrosis of bone.

Bone Involvement in Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by a wide variability of clinical manifestations due to the potential involvement of several tissues and internal organs, with a relapsing and remitting course. Dysregulation of innate and adaptive immune systems, due to genetic, hormonal and environmental factors, may be responsible for a broad spectrum of clinical manifestations, affecting quality of life, morbidity and mortality. Bone involvement represents one of the most common cause of morbidity and disability in SLE. Particularly, an increased incidence of osteoporosis, avascular necrosis of bone and osteomyelitis has been observed in SLE patients compared to the general population. Moreover, due to the improvement in diagnosis and therapy, the survival of SLE patient has improved, increasing long-term morbidities, including osteoporosis and related fractures. This review aims to highlight bone manifestations in SLE patients, deepening underlying etiopathogenetic mechanisms, diagnostic tools and available treatment.

Наш опыт лечения осложнений при повреждениях таранной кости

The article presents the features of treating consequences of severe lesions of ankle bone in 36 patients (the total of 40 lesions), hospitalized in the Department of adult traumatology of VTO Scientific-research Center — Science and Practice Center for Trauma of Republic Clinical Hospital in 1990-2022. Among the most severe complications of ankle bone is the development of avascular necrosis of ankle bone with fragmentation and lysis of fragments. The development of avascular necrosis of ankle bone took place in most cases of lesions and in 28 cases of fractures. The most severe complications took place in fractures of femoral neck and block with violations of congruency in adjacent joints and in full fracture-dislocations. The most feasible method of treating severe avascular necrosis of ankle bone with fragmentation and lysis of fragments was necrotomy with the formation of tibiotarsal arthrodesis.

BISPHOSPONATE INDUCED OSTEONECROSIS OF JAW – A CASE REPORT

Osteonecrosis of the jaw (ONJ), is the death or necrosis of a bone caused by an insufcient blood supply. It is also called as avascular necrosis, aseptic necrosis or ischemic necrosis of bone. It is a clinically devastating condition that can affect the quality of life of patients. ONJ can be induced by medication such as anti-resorptive agents such as bisphosphonates (BPs) and [1,2,3,4,8,9] antiangiogenic drugs, so is termed as medication related ONJ (MRONJ). The management of MRONJ can be conservative or invasive, [4,7] depending upon the stage of the disease, size of the lesions ,contributing drug therapy and presence of comorbidities. We report a case of bisphosphonate induced osteonecrosis of jaw managed successfully with conservative treatment.

Concomitant avascular necrosis of the lunate and proximal pole of the scaphoid in a thalassemia minor patient

Avascular necrosis (AVN) of multiple carpal bones is a very rare condition. This case report presents a patient with concomitant AVN of the lunate and proximal pole of the scaphoid that had led to severe joint space narrowing and degenerative arthritis in the radiocarpal and distal radioulnar joints (DRUJs). She was known to have thalassemia minor hemoglobinopathy. Wrist arthrodesis and distal ulna hemiresection-interposition arthroplasty (Bowers technique) for a DRUJ were offered and performed. The patient was satisfied with the clinical outcomes.

A case of lunatomalacia

Lunatomalacia is a condition characterized by avascular necrosis of the lunate bone. It is also known as osteonecrosis, Kienbock´s disease, and aseptic or ischemic necrosis of the lunate. Although the mechanisms by which this disorder develops are not fully understood, compromise of the bone vasculature is the most commonly proposed cause. Both extraosseous and intraosseous blood vessels supply the lunate bone. Vessels that enter the lunate through the dorsal and volar poles of the bone make up the extraosseous blood supply. Pathomechanics where acute trauma or repetitive minor trauma leads to direct vessel break and ligament disruption causes blood supply interruption and bone necrosis. A 31-year-old male presented to the orthopedics outpatient department with pain and swelling over the right wrist since 1 year. Patient gave alleged history of trauma to wrist while lifting heavy object and Pain was sudden in onset, gradually progressive in nature and dull aching type which got aggravated by lifting weights and got relieved by taking rest and medication. On local examination, tenderness presented over radial styloid, ulna styloid and medial radio-ulnar joint. Wrist range of motion (ROM) range normal and terminally painful. Fovea sign - positive, suggest triangular fibrocartilage complex injury. Pain on ulnar deviation of wrist. The patient was managed with a form of splinting.

Physiotherapy Rehabilitation in Idiopathic Chronic Osteomyelitis: A Case Report

Osteomyelitis is an infection-related inflammation of the bones and bone marrow. Generally in the legs, arms, spine. Foot and ankle osteomyelitis can be excruciatingly painful for patients and a difficult management challenge for orthopedic surgeons. Acute staphylococcal osteomyelitis had a 50% death rate in the pre-antibiotic era. Osteomyelitis of the foot and ankle can occur due to a variety of reasons, with diabetic foot infections being one of the most common. Osteomyelitis is a bone marrow inflammation which progression, involving the cortical plates and frequently periosteal tissues, along with the majority of cases occurring after bone trauma or surgery, or as a result of vascular insufficiency. Chronic nonbacterial osteomyelitis is an autoinflammatory disease that primarily affects children and adolescents and is characterized by recurrent or persistent osteitic foci. The symptom is bone pain, which may or may not be accompanied by soft tissue tenderness. Chronic osteomyelitis is related with avascular necrosis of bone along with the establishment or formation of sequestrum (dead bone), and surgical debridement, in addition to antibiotic therapy, is required for cure. Physiotherapy has effect in improving the quality of life of the patient with osteomyelitis.

Bone complications in Gaucher disease

Purpose: Gaucher disease (GD; OMIM # 230800) is an autosomal recessively inherited lysosomal storage disease. GD is caused by a deficiency of the lysosomal enzyme, glucocerebrosidase (GBA, also called acid ß-glucosidase or GCase), which hydrolyzes glucosylceramide (GlcCer) into ceramide and glucose. As a consequence of mutations in the GBA1 gene located on chromosome 1 (1q21) there is an accumulation of GCase substrate, GlcCer, in macrophages. Bone tissue represents a large systemic compartment of the human body, with an active metabolism that controls mineral deposition and removal, and where several factors may play a role. For these reasons, several non-skeletal diseases may influence bone metabolism. Methods: The present review describes bone skeletal manifestations in the GD and the role of several factors. This manuscript is the result of a review of the literature that focused on the bone manifestations of GD. In particular, relevant studies were identified through a PubMed search strategy. Step 1 consisted of a systematic literature search using the terms: Bone Metabolic Rare Diseases, Hematological Rare Diseases, Gaucher Disease; step 2 involved adding the terms “osteoporosis” or “bone mass”, or “bone turnover” or “bone fragility” or “bone deformity”, or “bone biomarkers”. Results: The skeletal manifestations of GD include a variety of bone pathologies due to various factors. These pathologies include bone infarcts, avascular bone necrosis, cortical thinning, lytic bone lesions, osteosclerosis and fractures due to osteopenia or osteoporosis, and rarely acute osteomyelitis. Conclusions: Bone loss in patients with GD should be managed, whenever possible, at or in close liaison with a center that specializes in the diagnosis, management and therapy of metabolic bone diseases. A multidisciplinary approach is important to better understand the complexity and pathogenesis of bone involvement in GD. In this way it will be possible to refine and standardize the diagnostic and therapeutic approaches to bone disease in GD.

Protein Phosphatase 6C (PPP6C) Loss Significantly Raises Fetal Hemoglobin Levels and Reduces Cell Sickling

Sickle cell disease (SCD) afflicts millions of people worldwide and can lead to severe complications including acute chest syndrome, stroke, avascular necrosis of bone, and nephropathy. Although increasing levels of fetal hemoglobin (HbF) significantly reduces cell sickling and SCD-related morbidity and mortality, effective HbF pharmacologic induction has remained an elusive goal. To identify additional potentially druggable molecules involved in HbF control, we carried out a domain-focused CRISPR-Cas9-based genetic screen targeting all protein phosphatases (1308 independent sgRNA representing 218 phosphatases). The phosphatase sgRNA library was cloned into a lentivirus scaffold and introduced into the erythroid cell line HUDEP2 stably expressing Cas9, and the top and bottom 10% of HbF-expressing cells were sorted and the integrated sgRNAs were sequenced. This screen identified a single protein phosphatase - PPP6C - as an HbF repressor.PPP6C is the catalytic subunit of protein phosphatase 6, a serine/threonine cytosolic protein phosphatase that is widely expressed across tissues and throughout erythroid development to broadly regulate mRNA translation. PPP6C has been implicated in numerous cellular functions, including cell cycle regulation, autophagy, and innate immunity, but its role in HbF regulation has not previously been described. Depletion of PPP6C by 5 independent sgRNAs in HUDEP2 cells resulted in significant HbF enrichment. Importantly, PPP6C depletion did not affect cellular viability or differentiation, suggesting that PPP6C may serve as a targetable HbF regulator for the treatment of SCD.To validate the findings of this genetic screen in primary human erythroid cells, we performed CRISPR-Cas9 ribonuclear protein (RNP)-based genome editing of PPP6C in a three-phase in vitro culture of adult CD34+ hematopoietic cells. HbF levels were assessed by RT-qPCR, Western blot, flow cytometry, and HPLC. We find that depletion of PPP6C protein levels by greater than 80% increases gamma-globin transcript levels in a dose-dependent manner to nearly 5 times basal levels. In addition, PPP6C loss leads to a greater than doubling in F-cell number and a 3-4-fold increase in HbF levels as measured by HPLC analysis. PPP6C depletion showed minimal effects on the erythroid transcriptome by RNA-Seq and did not significantly impair erythroid maturation. Mechanistically, loss of PPP6C leads to depletion of BCL11A protein levels by nearly 50% but unchanged levels of other key HbF regulators such as HRI and LRF, suggesting PPP6C-mediated HbF regulation may proceed at least in part via loss of BCL11A. However, additional studies are necessary to fully elucidate these underlying regulatory mechanisms. Importantly, depletion of PPP6C in SCD patient-derived cells was well tolerated, led to similar levels of HbF induction, and markedly reduced cell sickling by greater than 60%. Results from ongoing studies exploring the mechanism of PPP6C in HbF regulation will be discussed.Taken together, these data indicate that PPP6C functions in a dose-dependent manner to regulate HbF in primary erythroid cells and may serve as a therapeutic target in the treatment of SCD. DisclosuresBlobel: Fulcrum Therapeutics, Inc.: Consultancy; Pfizer: Consultancy.

Histopathology Findings of the Lunate in Stage III Kienböck's Disease.

Background: The etiology and natural history of Kienböck's disease remain unclear. Traditionally it has been defined as avascular necrosis of the lunate. The authors tried to demonstrate different tissue distribution, the area ratio of necrotic tissue and vessel counts inside the whole Kienböck lunate to reveal a dynamic process of the lunate collapse. Methods: Five lunates from patients with stage III Kienböck's disease and one cadaveric lunate not involved by Kienböck's disease were sampled. They were sectioned, H&E stained, and evaluated. The thickness of trabecular bone and the area of necrotic tissue were measured with Image-Pro Plus. The number of vessels was counted manually. Results: In the normal lunate, the bone trabeculae showed a uniform distribution with fatty marrow filled the interspace between the trabeculae. In the lunates with Kienböck disease, the trabeculae fracture and necrosis located in the central part with massive fibrous granular tissue proliferation. There were also some chondroid metaplasia at the palmar and dorsal ends. The trabeculae of the lunates of the Kienböck's disease [0.188 mm (0.153 mm, 0.236 mm)] was significantly thicker than the normal lunates [0.146 mm (0.124 mm, 0.164 mm)]. The necrosis was localized around the fracture sites instead of the whole lunate. The mean necrosis area only accounts for 16.3% ± 8.9% of the whole section. Such kind of focal necrosis is quite similar to those around the traumatic fracture ends of other bones. Even in stage III Kienböck lunates, the vessels are quite abundant (221 ± 42 in one sagittal section), while the vessels inside the normal lunate were 352 ± 28. Conclusions: There is neither massive nor obvious generalized avascular bone necrosis in our histopathology observations. The focal necrosis and vessel damage were more likely associated with the broken trabeculae inside the lunate. Based on our histopathology observations, we suggested that the progressive process of Kienböck's disease could be described as lunate nonunion advanced collapse instead of avascular necrosis.

Conservative and Surgical Treatment of Talar Fractures: A Systematic Review and Meta-Analysis on Clinical Outcomes and Complications.

The integrity of the talus is crucial for the physiologic function of the feet. The present study sought to summarize the available evidence on clinical outcomes and complications following conservative and surgical treatment of talar fractures. We systematically searched Medline via OVID to find relevant studies with a follow-up of at least six months. Hereafter, the success and complication rates were extracted and analyzed in a random effects proportion meta-analysis. Complications were defined as avascular bone necrosis (AVN) and posttraumatic osteoarthritis (OA). Additionally, a subgroup analysis was performed for fracture localization (talar neck fractures (TN) and combined talar body/neck fractures (TN/TB)) and severity of the fracture. The quality of the included studies was assessed utilizing the Coleman Methodology Score (CMS). A total of 29 retrospective studies, including 987 fractures with a mean follow-up of 49.9 months, were examined. Success rates were 62%, 60%, and 50% for pooled fractures, TN, and TN/TB, respectively. The overall complication rate for AVN was 25%. The rate was higher for TN (43%) than TN/TB (25%). Talar fractures revealed a 43% posttraumatic osteoarthritis (OA) rate in our meta-analysis. Success rates showed an association with fracture severity, and were generally low in complex multi-fragmentary fractures. The mean CMS was 34.3 (range: 19–47), indicating a moderate methodological quality of the studies. The present systematic review on clinical outcomes of patients undergoing conservative or surgical treatment for talar fractures reveals a lack of reliable prospective evidence. Talar fractures are associated with relatively poor postoperative outcomes, high rates of AVN, and posttraumatic osteoarthritis. Poor outcomes revealed a positive association with fracture severity. Prospective studies investigating predictors for treatment success and/or failure are urgently needed to improve the overall quality of life and function of patients undergoing surgical treatment due to talar fractures.

Avascular necrosis in systemic lupus erythematosus: total hip replacement in a patient with mutation in clotting factor V (Leiden) gene, clinical observation

The article provides a description of the systemic lupus erythematosus patient with multiple avascular bone necrosis (ABN), homozygous mutation in clotting factor V (Leiden) gene, who successfully underwent the total hip replacement. The role of high doses of glucocorticoids and coagulation disorders, in particular the homozygous mutation in factor V (Leiden) gene, in the development of ABN is discussed.

Imaging in ischemia of bone – A pictorial essay

Ischemia of bone is not uncommon and is not recognized clinically unless it is acute. Ischemia of bone marrow in shafts of long bones goes by the name of infarction and is well recognized. Ischemia of epiphysis, small bones and subarticular ends of bones goes by the name of avascular necrosis and ischemia of cortical bone goes by the name of Osteosclerosis. The imaging features of these three entities are described with differential diagnosis wherever necessary.

Risk factors for symptomatic Avascular Necrosis (AVN) in a multi-ethnic Systemic Lupus Erythematosus (SLE) cohort.

Avascular necrosis of bone (AVN) is increasingly being recognized as a complication of SLE and causes significant disability due to pain and mobility limitations. We studied the prevalence and factors associated with avascular necrosis (AVN) in a multiethnic SLE cohort. SLE patients who visited the outpatient clinic from October 2017 to April 2019 were considered eligible. Their medical records were reviewed to identify patients who developed symptomatic AVN, as confirmed by either magnetic resonance imaging or plain radiography. Subsequently, their SLE disease characteristics and treatment were compared with the characteristics of patients who did not have AVN. Multivariable logistic regression analyses were performed to determine the independent factors associated with AVN among the multiethnic SLE cohort. A total of 390 patients were recruited, and the majority of them were females (92.6%); the patients were predominantly of Malay ethnicity (59.5%), followed by Chinese (35.9%) and Indian (4.6%). The prevalence of symptomatic AVN was 14.1%, and the mean age of AVN diagnosis was 37.6 ± 14.4 years. Both univariate and multivariable logistic regression analyses revealed that a longer disease duration, high LDL-C (low density lipoprotein cholesterol), positive anti-cardiolipin (aCL) IgG and anti-dsDNA results, a history of an oral prednisolone dose of more than 30 mg daily for at least 4 weeks and osteoporotic fractures were significantly associated with AVN. On the other hand, hydroxychloroquin (HCQ), mycophenolate mofetil (MMF) and bisphosphonate use were associated with a lower risk of AVN. No associations with ethnicity were found. In conclusion, several modifiable risk factors were found to be associated with AVN, and these factors may be used to identify patients who are at high risk of developing such complications. The potential protective effects of HCQ, MMF and bisphosphonates warrant additional studies.

Transitory bone marrow oedema of the hip in pregnant patient with antiphospholipid syndrome: A case report

BackgroundTransient bone marrow oedema (BMO) of the hip presents with pain, is diagnosed by magnetic resonance imaging (MRI), and usually resolves within 6 months. Risk factors include pregnancy. Avascular necrosis of bone and an association with BMO are among the less common presentations of antiphospholipid syndrome (APS). Aim of the workTo present a young Croatian female APS patient who developed transient BMO during pregnancy which spontaneously resolved postpartum. Case reportAfter developing left leg deep vein thrombosis and positive lupus anticoagulant at 22 years old, the patient was diagnosed with primary APS. Antinuclear antibody was borderline, but classification criteria for SLE were not fulfilled. She had an early missed abortion during her first pregnancy while receiving low-weight molecular heparin (LWMH) (enoxaparin 40 mg), and her second pregnancy was to term with LWMH, aspirin, and hydroxychloroquine 200 mg daily. During the third trimester of this pregnancy, she developed excruciating bilateral hip pain to the point she could barely walk. Based on an MRI scan, the patient was diagnosed with bilateral BMO of the femoral head. The condition improved and resolved within four months with conservative treatment postpartum, as confirmed by followup MRI. ConclusionConsidering that pregnancy and APS are risk factors for BMO, both played a role in the development of BMO and the severity of presentation. This case report presents a differential diagnosis of hip pain in pregnant patients, especially with APS. Although APS is commonly associated with AVN, it may also be associated with transient BMO.

Avascular Necrosis of Bone in Patients with Uveitis Treated with Systemic Corticosteroids

ABSTRACT Purpose: To identify the prevalence, risk factors and outcomes of avascular necrosis (AVN) in patients with chronic uveitis. Methods: A retrospective study of patients with corticosteroid-induced AVN treated at Manchester Uveitis Clinic between 1991 and 2019. Results: From a cohort of 4478 patients, 1698 had been treated with systemic corticosteroids. Five patients with AVN were identified (prevalence 0.29%). The mean age at diagnosis of AVN was 49 years. All 5 patients were using systemic immunosuppression. Four patients developed femoral head AVN in 7 joints, one had bilateral knee osteonecrosis. The mean duration of corticosteroid before AVN was 38 months; the mean dose at onset was 17mg/day and the mean cumulative dose was 18,860mg. Three patients required total hip replacements but management was conservative for others. There was no permanent disability. Conclusions: AVN is a rare but severe complication of corticosteroid therapy. Clinicians should be vigilant for symptoms of bone pain as early detection and cessation of corticosteroids can reverse incipient AVN and avoid surgery.

Peri-Operative Management of a Patient with Sickle Cell Disease for Total Hip Replacement: Case Report

Introduction: Sickle cell disease is an inherited disorder, with multiorgan dysfunction resulting from vaso-occlusion and chronic haemolysis. Avascular necrosis of long bones is a known complication. Anaesthetists are frequently involved throughout perioperative period, which involves preoperative assessment, management of acute pain and prevention of postoperative complications.