Bilateral Femoral Head Necrosis Research Articles

Ayurveda in the Management of Avascular Necrosis of Femoral Head - A Case Report

Avascular necrosis (AVN) is defined as cellular death of bone components due to interruption of the blood supply. The bone structures then collapse, resulting in pain, loss of joint function and long-term joint damage. Treatment goals for AVN are to improve the joint, stop the bone damage, and ease pain. In modern science treatment includes NSAIDS, core decompression, bone grafting and total joint arthroplasty which have their own complications, high cost and prognosis is also very poor. In Ayurveda it can be correlated to the Asthi-Majja gatha vata. In this Raktavaha Srotorodha also occur which results in Asthi Dhatu Kshaya. Aim of study is to introduce an alternative therapeutic modality through Ayurveda which help to reduce pain, improve quality of life and prevent further damage of bone which is cost effective as well. The present case report is a single case study of a 32year old female patient who was diagnosed with Stage Ⅱ Avascular Necrosis of bilateral femoral head done at Government Ayurveda College Panchakarma Hospital, Poojappura, Thiruvananthapuram. She was treated with selected Panchakarma treatments and specific Samana oushadhis. There was significant improvement in the symptoms which was assessed using relevant tools like VAS score for pain, goniometer for range of movement and Oxford Hip score for assessment of function and pain in hip. The present case study documents that Panchakarma procedures and Samana oushadhis can be effective in AVN and improve the quality of life of patient.

Analysis of influence of MR signs on Harris score in ARCO stages 2-4 femoral head necrosis

To analysis and determine MR signs of Harris score ARCO stages 2-4 in osteonecrosis of femoral head (ONFH). Thirty-four patients with ONFH of ARCO stages 2 to 4 who underwent routine MR, T2 mapping, 3D-SPACE sequence examination and Harris score were retrospectively collected from January 2019 to June 2020, and 3 patients were excluded, and 31 patients were finally included, including 23 males and 8 females, aged from 18 to 62 years old with an average of(40.0±10.8) years old. Among them 21 patients with bilateral femoral head necrosis, totally 52 cases, including 17 with ARCO stage 2 patients, 24 ARCO stage 3, and 11 ARCO stage 4. MR imaging signs (femoral head collapse depth, ONFH index, bone marrow edema, hyperplasia, grade and T2 value of cartilage injury, and joint effusion) were scored and measured on the picture archiving and communication system (PACS) workstation, and the cartilage quantitative parameter T2 value was calculated and measured on Siemens postprocessing workstation. Pearson correlation analysis was used to evaluate the correlation between various MR signs and Harris score, and then multiple linear regression analysis was used to examine impact of MR signs on Harris hip score. Femoral head collapse depth(r=-0.563, P=0.000), grade of cartilage injury(r=-0.500, P=0.000), and joint effusion (r=-0.535, P=0.000) were negatively correlated with Harris score by Pearson correlation analysis. Multiple linear regression analysis showed that joint effusion(β=-6.198, P=0.001) and femoral head collapse depth(β=-4.085, P=0.014) had a significant negative impact on Harris hip score. Femoral head collapse depth and joint effusion both had significant negative relationship with Harris hip score. It is recommended to routinely evaluate femoral head collapse depth and joint effusion quantitatively and gradedly, so as to efficiently and accurately assist clinical diagnosis and treatment.

Bilateral avascular necrosis of femoral heads after pelvic irradiation: A case report and systematic review

The development of radiation induced changes in bone is related to multiple factors such as total dose, per fraction dose, irradiated volume, bone structure and localization, patient age, and chemo-radiotherapy. It is known that chang-es in bone occur after 30-40 Gy. There are very few publications on this subject in the literature, mostly case reports. Therefore, there is no definite consensus about the pathogenesis, diagnosis, and treatment. In this report, a case of avascular necrosis of bilateral femoral heads after pelvic radiotherapy will be presented and the relevant literature will be reviewed.

Bilateralna avaskularna nekroza glave butne kosti nakon infekcije COVID-19 - prikaz slučaja

Introduction: Despite having a substantial impact on survivors' mobility and leading to morbidity, musculoskeletal involvement was the post-COVID-19 infection sequelae area that received the least attention in the literature. Reviewing the COVID-19 histories of patients who visited a tertiary health center, the research is aimed at finding an association between COVID-19 infection and avascular femoral head necrosis, a condition brought on by insufficient blood flow. Avascular necrosis of the femoral head is a condition characterized by a restricted range of motion, pain, and disturbance of gait. It is brought on by insufficient blood flow. Case reports: We discussed several examples in which COVID-19 caused individuals to develop bilateral femoral head necrosis. When COVID-19 infection is the only factor present, and corticosteroids are used to treat it, avascular necrosis of the femoral head may become more prevalent. Detecting avascular necrosis of the femoral head in its early stages, hip MRI might reduce the patient's disability and need for continuous treatment. Conclusion: Early identification and treatment of AVN patients reduce the need for surgery and the chance of disabilities.

Avascular Necrosis of Femur as a Complication of Cushing's Syndrome Due to Adrenocortical Carcinoma.

A wide range of clinical presentations for Cushing's syndrome has been described in the literature. Avascular necrosis of femur is a well-recognized complication of excessive glucocorticoid administration, but its occurrence due to endogenous hypercortisolism is rare. We present the case of a 47-year-old male who presented to us with severe low backache, hypertension, uncontrolled diabetes, and other signs and symptoms of Cushing's syndrome. Hormonal evaluation confirmed hypercortisolism, and a contrast-enhanced computed tomography of the abdomen localized the lesion in the left adrenal gland. Assessment of the severe low back ache-the main symptom for which the patient came to us-by magnetic resonance imaging of the spine and pelvis revealed avascular necrosis of bilateral femoral heads. Resection of the left adrenal gland revealed an adrenocortical carcinoma. To the best of our knowledge, this is only the second case where an adrenocortical cancer leading to hypercortisolism is the cause of avascular necrosis of hip.

Avascular necrosis of bilateral femoral head in a HIV patient

Avascular necrosis (AVN) is due to ischemic death of the bone involving typically the femoral heads. Its incidence rate is higher in HIV-infected patients and is multifactorial. The factors such as dyslipidemia, alcohol use, steroid use, protease inhibitor in highly active anti-retroviral therapy (HAART) regimen and HIV infection itself increases the incidence of AVN. Here, we report the case of 52-year-old female with a history of pain in bilateral hip joint with no history of trauma. She was a known case of retroviral disease since 9 years and was on HAART. On examination, her vitals were stable, and she had restriction in both passive and active movements around bilateral hip joint, and they were painful. There was no obvious swelling, and other joints were normal. General and systemic examinations, including neurological and musculoskeletal, were normal. Laboratory parameters showed hematological renal and liver functions to be normal, but total cholesterol was 285 mg/dl and triglycerides were 231 mg/dl. Magnetic resonance imaging showed STIR hyperintense band sign corresponding to T1 hypointense rim suggestive of bilateral AVN of head of femur (FICAT and ARLET Classification Stage 1). The aim of this case report is to alert the clinicians involved in HIV care regarding AVN as a subtle yet frequent complication in a HIV-infected patient with known predisposing factors when presenting with acute spontaneous nontraumatic bilateral hip joint pain.

Can large doses of glucocorticoids lead to Perthes? a case report and review of the literature

BackgroundPerthes disease (Legg-Calvé-Perthes, LCP) is a self-limited and non-systemic disease occurring in the femoral heads of children, which is mainly manifested as an ischemic necrosis of the femoral head epiphysis, leading to subchondral ossification injury of the femoral head.Case presentationHere we report a case of 11-year-old child with long-term use of high-dose glucocorticoids. With MRI examination finding the epiphyseal necrosis of right humeral head, femur and tibia, and X-ray examination finding bilateral femoral head necrosis, the child was diagnosed as Perthes disease based on his clinical and imaging data.ConclusionsLong-term and high-dose glucocorticoids may be one of the causes of Perthes disease.

Washed microbiota transplantation for the treatment of recurrent fungal infection in a patient with ulcerative colitis.

Washed microbiota transplantation for the treatment of recurrent fungal infection in a patient with ulcerative colitis.

Steroid induced avascular necrosis of femoral head in ALL patients-two case reports

Avascular necrosis of bone or Osteonecrosis incidence has been increasing in a larger number of surviving ALL patients, especially in adolescents and young adults [1]. Osteonecrosis and decreased bone mineral density(BMD) are well-known side effects of corticosteroids and avascular necrosis has been reported as one of the leading causes of treatment related morbidity in ALL survivors [2]. Symptomatic avascular necrosis has been reported to occur in up to 20% of children and adolescents with ALL [3]. We are reporting two cases of ALL patients who have been treated with steroid and chemotherapy and developed avascular necrosis of bilateral femoral heads.

Probiotics for maintenance of remission in ulcerative colitis.

Probiotics for maintenance of remission in ulcerative colitis.

Comparing the efficacy of core decompression with autologous bone marrow mononuclear cell grafting with impacted bone grafting in treating bilateral femoral head necrosis

Objective To compare the efficacy of core decompression with autologous bone marrow mononuclear cell grafting with impacted bone grafting in treating bilateral femoral head necrosis. Methods From January 2011 to January 2017, a total of 44 patients with bilateral femoral head necrosis (88 hips) were admitted to the Department of Orthopaedics, China-Japan Friendship Hospital, including 35 males and 9 females with aged 34.9±7.2 years old (ranged from 22-48 years). Core decompression with autologous bone marrow mononuclear cell and impacted bone grafting were conducted to each hip joint for every patient. All patients were followed up for every 3 months at the first year postoperatively and for every 6 months thereafter. The following clinical measurement were recorded, Harris hip score (HHS), visual analogue score (VAS), the anterior-posterior and frog lateral radiographs, and CT. The 5-year survival rate of the hip was calculated with the endpoint event being defined as a need for total hip arthroplasty or other surgical intervention, or a HHS less than 70. Results The postoperative follow-up duration was 50.5±34.2 months in the impacted bone grafting group and 54.0±33.1 months in the core decompression with autologous bone marrow mononuclear cells group. Fifteen hips in the impacted bone grafting group and 13 hips in the core decompression with autologous bone marrow mononuclear cell group failed during the follow-up. The 5-year cumulative survival rates of the hips in two groups were 64.7% and 72.1%, respectively [HR=1.178, 95%CI(0.561, 2.477)]. In the impacted bone grafting group, the 5-year survival rates of the hip joints at the ARCO IIIB+IIIC and IIIA stages were 42.9% and 74.2%, respectively [HR=3.258, 95%CI(1.172, 9.059)]. In the core decompression with autologous bone marrow mononuclear cell group, the 5-year survival rates of hips at the ARCO stage I, II and IIIA stages were 50.0%, 75.3%, and 71.4%, respectively (χ2=0.757, P=0.685). Age, gender, BMI, preoperative HHS and etiology did not affect the effects of core decompression with autologous bone marrow mononuclear cell grafting or impacted bone grafting (P>0.05). The preoperative VAS of the impacted bone grafting group and the core decompression with autologous bone marrow mononuclear cell grafting group were 4.80±0.62 and 3.27±1.17, respectively (t=8.625, P<0.001). At the last follow-up, the VAS was reduced to 2.84±1.95 and 2.25±2.08, respectively (t=2.712, P=0.01; t=7.087, P<0.001) with significant difference in postoperative VAS between the two groups (t=2.489, P=0.017). The preoperative HHS of the impacted bone grafting group and the core decompression with autologous bone marrow mononuclear cell grafting group were 77.02±5.03 and 82.57±5.71, respectively (t=7.822, P<0.001). At the last follow-up, the HHS increased to 81.57±12.81 and 83.55±12.87, respectively. The difference between the preoperative and postoperative HHS was statistically significant in the impacted bone grafting group (t=2.389, P=0.021) but not in the core decompression with autologous bone marrow mononuclear cell grafting group (t=0.451, P=0.654). There was no significant difference in postoperative HHS between the two groups (t=1.353, P=0.183). Conclusion Both impacted bone grafting and core decompression with autologous bone marrow mononuclear cell grafting are safe and effective methods in treating femoral head necrosis. The ARCO stage is a risk factor affecting the prognosis of hips after impacted bone grafting, which has no effect on the mid-term survival of hips after core decompression with autologous bone marrow mononuclear cell grafting. Key words: Femur head necrosis; Bone transplantatio; Transplantation, autologous; Bone marrow transplantation

Orthopaedic robot-assisted free vascularised fibular grafting for the treatment of avascular necrosis of the femoral head

Objective To introduce the surgical procedure of orthopaedic robot-assisted vascularised fibular grafting for the treatment of ANFH and report the short-term result. Methods From September, 2016 to November, 2018, 17 patients (21 hips) with ANFH had undergone robot-assisted free fibular grafting. There were 14 males and 3 females, of which, 8 cases were associated with the right side, 5 cases the left side, and 4 cases with both sides. The average age was 35 (ranged from 17 to 55) years. There were 7 patients suffered from idiopathic ischemic necrosis of femoral head, 4 patients who had cannulated screws fixed after a femoral neck fracture, 4 patients who had a history of alcohol consumption, 1 patient who had taken corticosteroids for 6 months to treat nephritis, and 1 patient who had a history of alcohol consumption and had also taken corticosteroids. Seventeen hips were in Ficat stage II, and 4 hips were in Ficat stage III. The orthopaedic surgical robot workstation was used to plan the entry point and target of the guide pin during the operation, to place a cannula in the optimal position. Then a bone window was created and the fibula was placed into the bone tunnel. Using fluoroscopy to monitor each step of the procedure and verify the position of the fibula. Finally, the vessels were anastomosed. The patient remain in bed completely for a week with the use of vasodilator. The follow-up was accomplished with phone call and outpatient clinic, and Harris score was evaluated. Results All 21 surgical procedures were successful. The guide pins and fibula were accurately placed according to the robot’s plan, and the tips of the fibula were placed at the centre of the load-bearing region of the femoral heads, 4 to 6 mm from the articular surface. Conventional anticoagulant, anti-infective therapy was performed after the procedure. Ten patients were followed-up postoperatively more than 1 year, with an average of 15 (from 12 to 24) months. The function of the hip joint recovered smoothly for 9 patients. Frontal and lateral X-ray and CT scans showed that the tips of the fibula were placed at the centre of the load-bearing region, 4 to 6 mm from the articular surface. One patient suffered from bilateral femoral head necrosis and the right side recovered smoothly after operation. However, joint movement was restricted for the left hip and the pain was significant. An arthroscopic examination was performed 1 month after the operation and did not identify any problems such as intraarticular incular infection or articular surface of the femoral head was protruded by the tip of the fibula. The symptoms were alleviated after removing the osteophytes at the rim of the acetabulum. The Harris score was 62.4±13.6 before operation, and 84.5±4.5 at the last time of followed-up after operation. The difference in Harris scores was statisticly significant (P<0.05). Conclusion With the assistance of an orthopaedic robot system, the guide pin can be accurately positioned, thereby allowing the tip of the fibula to be inserted into the optimal anatomical position and maximising its mechanical efficacy. In theory, it is the best choice for performing fibular bone transplantation in ANFH. And the early effect of treatment is good. Key words: Avascular necrosis of femoral head; Orthopaedic robot; Fibula grafting; Microsurgical technique

Bilateral femoral head necrosis with low dose oral corticosteroid therapy for pan-hypopituitarism

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Successful Treatment of Total Hip Arthroplasty to a Patient Associated with Alcoholic Cirrhosis and Severe Plated Deficiency with Preoperative Partial Splenic Embolization

Introduction: We present the first report of the successful treatment of Total Hip Arthroplasty (THA) to a patient associated with alcoholic cirrhosis and plated deficiency undergoing preoperative Partial Splenic Embolization. Case Report: A 45-year woman who had Liver Cirrhosis (LC) and alcohol residue heritage failure suffered from severe groin pain and had a difficulty in walking for a long period due to avascular necrosis of bilateral femoral head. She was referred to our orthopaedic service and THA was planned. Despite preoperative transfusion for her platelet deficiency coursed by LC, preoperative platelet count decreased less than a normal range. Therefore, Partial Splenic Embolization (PSE) was applied to her so as to increase platelet count. PSE could temporally reduce the portal vein pressure and prevent a hyperspleism and cytopenia. After the procedure, THA was performed to bilateral hip safely through a direct anterior approach. At the time of the latest follow-up, the patient had an excellent clinical result. Conclusion: Preoperative PSE may be a useful procedure to the patients with LC and severe plated deficiency who need arthroplasty including THA. Pre-existing physical and psychological factors have an effect on the outcome of arthroplasty and appropriate strategies might be needed.

Microbubble-Mediated Ultrasound Outweighs Low-Intensity Pulsed Ultrasound on Osteogenesis and Neovascularization in a Rabbit Model of Steroid-Associated Osteonecrosis.

Microbubbles magnify the acoustic pressure of low-intensity pulsed ultrasound (LIPUS) and may enhance its bioeffect for diagnostic and therapeutic purposes. This study compared the effect of this novel microbubble-mediated ultrasound (MUS) with that of the traditional LIPUS on osteogenesis and neovascularization in a rabbit model of steroid-associated osteonecrosis. We hypothesized that MUS might outweigh LIPUS on promoting osteogenesis and neovascularization in steroid-associated osteonecrosis. The bilateral femoral head necrosis was induced by lipopolysaccharide and methylprednisolone in the rabbits. The indices of bone mineral density (BMD), trabecular number, maximal loading strength, and mineral apposition rate were analyzed, demonstrating that the animal model of steroid-associated osteonecrosis was successfully established. Both the MUS group (GM) and the LIPUS group (GL) were insonated 20 min daily for six weeks. GM received an extra intracapsular injection of microbubbles before insonation every other day. Fluorescence bone labeling, Micro-CT Analysis, biomechanical test, quantitative real-time PCR, Western blot analysis, and histological evaluation were performed for comparing GM with GL. The results demonstrated a 39% higher mineral apposition rate in GM compared with GL. The BMD and the maximal loading strength of femoral head of GM increased by 4.3% and 27.8% compared to those of GL, respectively. The mRNA and protein expression of BMP-2 and VEGF were also significantly higher in GM. The number of blood vessels of GM was 65% greater than that of GL. MUS is more potent than LIPUS in enhancing osteogenesis, neovascularization, and biomechanical strength of femoral head in the animal model of steroid-associated osteonecrosis. Without increasing the intensity of insonation or the risk of tissue damage, MUS is better for inhibiting the process of steroid-associated osteonecrosis.

Abstract #552 2 Cases of Avascular Necrosis of Bilateral Femoral Head with Very Low Doses of Oral Steroids

Abstract #552 2 Cases of Avascular Necrosis of Bilateral Femoral Head with Very Low Doses of Oral Steroids

One-stage bilateral implantation of acalcar-guided short-stem intotal hip arthroplasty : Minimally invasive modified anterolateral approach in supine position.

ObjectiveOne-stage bilateral, muscle-preserving, calcar-guided implantation technique through the modified minimally invasive anterolateral approach in supine position.IndicationsBilateral primary/secondary osteoarthritis of the hip; bilateral femoral head necrosis; ASA I–III.ContraindicationsASA IV; severe osteoporosis, other factors jeopardizing stable anchorage of cementless, calcar-guided short-stem; infection.Surgical techniqueSupine position. Skin incision. Opening of fascia; blunt dissection, pushing gluteal muscles dorsally with the index finger. Capsulectomy. Individual osteotomy according to preoperative plan to determine short-stem position. Remove femoral head. Prepare acetabulum. Position cup. Femoral preparation with the curved opening awl. Spare greater trochanter and gluteal muscles. Insert trial rasps in ascending sizes with “round-the-corner” technique. Select offset version, then trial reposition with intraoperative radiograph and implantation of the definitive implant. Wound closure. Consultation with the anesthesiologist to confirm a stable patient. Same procedure on contralateral hip.Postoperative managementMobilization on day 1 with immediate full weight bearing. Remove wound drains and urinary catheter (only female patients) on day 2. Intensive protocol of physiotherapy and rehabilitation. Thrombosis prophylaxis. Rehabilitation from day 7.ResultsAlmost 500 patients have undergone surgery since 2010. First consecutive 54 patients (108 hips) prospectively evaluated. After 2 years, Harris Hip Score was 98.8; satisfaction on visual analogue scale was 9.9. Low peri- and postoperative complication rates; no implant revisions.ConclusionThe muscle-sparing approach and the special “round-the-corner” technique in one-stage bilateral procedure leads to rapid mobilization and rehabilitation with excellent early clinical results and high satisfaction rates.

Spontaneous Avascular Necrosis of Bilateral Femoral Heads–Case Report

Avascular necrosis of femur as the name implies is directly related to the compromising state of the blood supply and their further pathological changes at that site. This results in major musculoskeletal disability. This may be traumatic or non-traumatic as the crux of the underlying problem is ischemia because of disruption of the vascular nourishment. This eventually leads to the death of marrow and osteocytes which leads to osteonecrosis. This shows in imaging in the form of ischemia or bone collapse and the diagnosis is made with the help of imaging armamentarium. The age of presentation and the history are very important to know before the diagnosis is made. Plain radiography, Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) play a pivot role in clinching the diagnosis. We present 28-years old male who reported with pain in both hip joints with painful and restricted movements. He was diagnosed as bilateral avascular necrosis of hips on the basis of the radiological findings.

Low-intensity pulsed ultrasound enhances bone repair in a rabbit model of steroid-associated osteonecrosis.

Steroids are a leading cause of femoral head osteonecrosis. Currently there are no medications available to prevent and/or treat steroid-associated osteonecrosis. Low-intensity pulsed ultrasound (LIPUS) was approved by the FDA for treating delayed union of bone fractures. Some studies have reported that LIPUS can enhance bone formation and local blood flow in an animal model of fracture healing. However, whether the effect of osteogenesis and neovascularization by LIPUS can enhance the repair progress in steroid-associated osteonecrosis is unknown. We hypothesized that LIPUS may facilitate osteogenesis and neovascularization in the reparative processes of steroid-associated osteonecrosis. Using a rabbit animal model, we asked whether LIPUS affects (1) bone strength and trabecular architecture; (2) blood vessel number and diameter; and (3) BMP-2 and VEGF expression. Bilateral femoral head necrosis was induced by lipopolysaccharide and methylprednisolone in 24 rabbits. The left femoral heads of rabbits received LIPUS therapy (200 mW/cm(2)) for 20 minutes daily and were classified as the LIPUS group. The right femoral heads of the same rabbits did not receive therapy and were classified as the control group. All rabbits were euthanized 12 weeks after LIPUS therapy. Micro-CT, biomechanical testing, histologic evaluation, immunohistochemistry, quantitative real-time PCR, and Western blot were used for examination of the effects of LIPUS. Twelve weeks after LIPUS treatment, the loading strength in the control group was 355 ± 38 N (95% CI, 315-394 N), which was lower (p = 0.028) than that in the LIPUS group (441 ± 78 N; 95% CI, 359-524 N). The bone tissue volume density (bone volume/total volume) in the LIPUS group (49.29% ± 12.37%; 95 % CI, 36.31%-62.27%) was higher (p = 0.022) than that in the control group (37.93% ± 8.37%; 95 % CI, 29.15%-46.72%). The percentage of empty osteocyte lacunae in the LIPUS group (17% ± 4%; 95% CI, 15%-20%) was lower (p = 0.002) than that in the control group (26% ± 9%; 95% CI, 21%-32%). The mineral apposition rate (μm/day) in the LIPUS group (2.3 ± 0.8 μm/day; 95% CI, 1.8 2.8 μm/day) was higher (p = 0.001) than that in the control group (1.6 ± 0.3 μm/day; 95% CL, 1.4-1.8 μm/day). The number of blood vessels in the LIPUS group (7.8 ± 3.6/mm(2); 95% CI, 5.5-10.1 mm(2)) was greater (p = 0.025) than the number in the control group (5.7 ± 2.6/mm(2); 95% CI, 4.0-7.3 mm(2)). Messenger RNA (mRNA) and protein expression of BMP-2 in the LIPUS group (75 ± 7, 95% CI, 70-79; and 30 ± 3, 95% CI, 28-31) were higher (both p < 0.001) than those in the control groups (46 ± 5, 95% CI, 43-49; and 15 ± 2, 95% CI, 14-16). However, there were no differences (p = 0.114 and 0.124) in mRNA and protein expression of vascular endothelial growth factor between the control (26 ± 3, 95% CI, 24-28; and 22 ± 6, 95% CI, 18-26) and LIPUS groups (28 ± 2, 95% CI, 26-29; and 23 ± 6, 95% CI, 19-27). The results of this study indicate that LIPUS promotes osteogenesis and neovascularization, thus promoting bone repair in this steroid-associated osteonecrosis model. LIPUS may be a promising modality for the treatment of early-stage steroid-associated osteonecrosis. Further research, including clinical trials to determine whether LIPUS has a therapeutic effect on patients with early-onset steroid-associated osteonecrosis may be warranted.

Avascular Necrosis of Bilateral Femoral Heads in a Patient with Fabry's Disease

The underlying cause of avascular necrosis (AVN) of the femoral head is often not apparent. We report the case of a 26 year old builder with a four month history of bilateral hip pain, and a diagnosis of bilateral femoral head avascular necrosis. Fabry's disease was identified as the probable cause. Since 2001, enzyme replacement therapy for Fabry's disease has become available, with a potential to influence the disease process, and this is of potential importance to clinicians treating AVN.