Bilateral Femoral Head Research Articles

A case report: Atypical bilateral idiopathic femoral head necrosis requiring differentiation from tumor

A case report: Atypical bilateral idiopathic femoral head necrosis requiring differentiation from tumor

Normal tissue sparing using different techniques for prostate irradiation.

The aim of this study was to investigate normal tissue sparing through dosimetric parameters of normal tissue volumes using different irradiation techniques for conventional (CFRT) and simultaneously integrated boost (SIB) schedules. Several dose-escalation studies for localized prostate cancer (PCa) have shown advanced biochemical relapse-free (bRFS) rates and also better local control for higher total doses using either CFRT or SIB schedules. Besides the most important organs-at-risk, absorbed dose reduction of other surrounding normal tissues are also preferable. In order to analyse the normal tissue sparing, dosimetric parameters of different normal tissue volumes were examined. Treatment plans for 15 high risk prostate cancer patients were created using RapidArc (RA), Sliding Window (SW) IMRT and 4-field box (3D-CRT) technique. In order to evaluate normal tissue sparing, the volume of pelvic region was divided into six normal tissue cylinders with 1cm wall thickness, located in each other. All plans met the criteria of target coverage (V95%>95%). All techniques provided the same results for OARs except 3D-CRT for rectum and bilateral femoral heads. The values of V5, V10 and V15 increased in cases which included RapidArc technique and decreased for V20 and V30. The dosimetric parameters for the cylindrical normal tissue volumes show that using RapidArc technique gives equal or slightly better normal tissue sparing and SIB provided the same normal tissue sparing as CFRT planned with RapidArc.

One-stage simultaneous hip-preserving surgeries for the management of bilateral femoral head osteonecrosis: a mean 7.0-year follow-up

BackgroundA retrospective study was conducted to evaluate and compare the clinical and radiological outcomes of one-stage fibular impaction allografting and vascularized greater trochanter flap autografting for the treatment of bilateral osteonecrosis of the femoral head (ONFH).MethodsPatients who underwent one-stage aforementioned hip-preserving surgeries due to bilateral ONFH were retrospectively reviewed from January 2008 to December 2013. Sixty-nine patients (138 hips) with a mean age of 31.5 years and mean follow-up of 7.0 years were included. Hips that underwent fibular impaction allografting and vascularized greater trochanter flap autografting were assigned as group A and group B, respectively. Harris Hip Score (HHS) and Visual Analogue Scale (VAS) were used for clinical evaluation, and a series of X-ray images were used for radiological assessment. For inter-group analysis, the paired t test was used for continuous data, and the Wilcoxon rank sum test was used for non-parametric data, while the Mann-Whitney U test was used for intra-group analysis.ResultsThe HHS and VAS in both groups A and B had a substantial advancement when compared with the preoperative level (p < 0.01). Fibular impaction allografting can achieve more pain relief (p < 0.01), though no clinical difference was found in terms of minimal clinically important difference (MCID < 10 points). Group A showed better radiological results than group B (p = 0.04). It was discovered that the appropriate indication for each procedure was patients with Association for Research on Osseous Circulation (ARCO) stages II and III, respectively.ConclusionOne-stage hip-preserving surgeries for the management of bilateral ONFH could obtain good medium and long-term outcomes. It was recommended that fibular impaction allografting is more suitable for patients in ARCO stage II, while for patients in ARCO stage III, vascularized greater trochanter flap autografting is a better preference.Trial registrationRetrospectively registered.

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

Adie’s tonic pupil in sjogren's syndrome

Adie’s tonic pupil is a neurological disorder more common in women. It is characterized by persistent unilateral mydriasis. Tonic pupil constricts poorly to light but reacts better to accommodation. It is caused by parasympathetic ciliary ganglion damage and is characterized by hypersensitivity to muscarinic receptor agonists (pilocarpine). Most cases are idiopathic, though it can be caused by autoimmune diseases, tumors, trauma, and surgery. We report a case of a 39-year-old woman with a past medical history for migrainous headache, left knee and bilateral femoral head osteonecrosis, anemia and arthritis. She was diagnosed with sjogren syndrome based on symptoms of mouth and eyes dryness, positive serum anti-RO/SSA and ANA antibodies and labial salivary gland biopsy showing lymphocytic sialadenitis. She presented with progressive vision loss in the right eye. The initial examination showed anisocoria, an afferent pupillary defect and a sector pupil palsy of the right eye. Ophthalmoscopic evaluation, visual acuity and field testing were normal. Visual-evoked potentials (VEPs) were normal. Ankle jerk reflexes were absent. The diagnosis of Adie’s tonic pupil was confirmed with rapid miotic response of the affected pupil to 0.125% pilocarpine drop. The patient was treated with Pilocarpine drops and had slightly improved symptoms. Adie’s tonic pupil is a benign, mostly idiopathic syndrome caused by parasympathetic denervation. However, it can be associated with infectious, inflammatory, malignant, or autoimmune pathologies. Systemic conditions associated with tonic pupils are rare. This is, as far as we know, the first case reported of a sjogren syndrome associated with tonic pupil.

Adjuvant Bone-Marrow Sparing IMRT in Endometrial Cancer Patients Treated with Sequential Chemotherapy- Does it Help with Completion Rate?

Postoperative pelvic IMRT has been shown to have decreased rates of myelosuppression in patients with gynecologic cancers treated with concurrent chemoradiation therapy, when compared to conventional 3D-CRT. However, there is limited data on how marrow sparing IMRT might impact tolerance in the setting of full-dose sequential chemotherapy and extended-field radiotherapy. A retrospective analysis of 158 patients with endometrial cancer treated with adjuvant sequential chemoradiation therapy with marrow sparing IMRT from 2008-2018 was performed. 146 of 158 patients received pre-IMRT chemotherapy, with 14 of 158 receiving post-IMRT chemotherapy. 63 patients were treated with extended field IMRT to include para-aortic lymph nodes, while 95 were treated with pelvic field IMRT including the entire common iliac region. Bone marrow was defined dosimetrically as the pelvic bone, bilateral femoral heads, and lower lumbosacral spine, with goal bone marrow V20 Gy < 80%. Myelosuppressive events were categorized using RTOG criteria. Linear regression analysis was used to assess for correlation between myelosuppression events and bone marrow dose. 157 of 158 (99.4%) patients completed EBRT as prescribed, with 1 discontinuing treatment due to acute GI toxicity. Median EBRT treatment time was 35 days (range 32-60 days). Total EBRT treatment time was 40 days or more in 17 patients (11%), with 4 patients having prolonged EBRT treatment time attributable to myelosuppression (range 42-57 days). All 158 patients had CBCs during treatment (median 4, range 1-8). Results for myelosuppressive events are detailed in the table below. Bone marrow V20 <80% was met in 118/158 (75%) of patients. Median bone marrow mean dose was 29.1 Gy (range 19.4-35.8 Gy). Median bone marrow V20 Gy was 73.9% (range 47.1-91.0%). Linear regression analysis did not reveal statistically significant associations between V20 Gy or mean bone marrow dose with grade 2 myelosuppression events. Grade 3 myelosuppression were rare events, with 2% incidence in pelvic field IMRT and 5% incidence in extended field IMRT. This is the largest series with marrow sparing IMRT in patients with endometrial cancer treated with sequential chemoradiation therapy, showing very low rates of grade III myelosuppression and 99.4% completion rate, with few treatment interruptions. With our goal bone marrow V20 Gy <80% dose met in the majority of patients, we were unable to determine a statistically significant relationship between myelosuppression events and V20 Gy or mean bone marrow dose.Abstract 2808; Table 1Grade 2 Anemia (Hgb<9.5-7.5)Grade 3 Anemia (Hgb <7.5)Grade 2 Neutropenia (ANC <1500-1000)Grade 3 Neutropenia (ANC <1000)Grade 2 Thrombocytopenia (PLT<75-50)Grade 3 Thrombocytopenia (PLT<50)Any Myelosuppression EventAny Grade 3 EventFrequency (n=158)20/158 (13%)0/158 (0%)33/158 (21%)4/158 (3%)8/158 (5%)1/158 (1%)53/158 (34%)5/158 (3%) Open table in a new tab

Osteopoikilosis

A 39-year-old man presented to the orthopaedic clinic with a 1-month history of sacrococcygeal pain. The patient denied experiencing any other constitutional symptoms and any other disorders, and no history...

Investigation of differences of sacral and vertebral bone mineral densities before and after radiotherapy in patients with locally advanced rectal cancer

PurposeRadiotherapy is a treatment method performed using ionizing radiation on cancer patients either alone or with surgery and/or chemotherapy. Although modern radiotherapy techniques provide a significant advantage in protecting healthy tissues, it is inevitable that normal tissues are also located in the areas targeted by radiations. In this study, we aimed to examine the bone mineral density changes in bone structures commonly included in the irradiated area such as, L5 vertebra, sacrum, and femur heads, in patients who have received pelvic radiotherapy; and the relationship between these changes with radiation dose. Material and methodsPatients included in the study had been previously diagnosed with rectal cancer, which were operated or not. Preoperative or postoperative pelvic radiotherapy was planned for all patients. In terms of convenience when comparing with future scans, all densitometry and CT scans were performed with the same devices. Fifteen patients were included in the study. In order to determine the dose of radiation each identified area had taken after radiotherapy, the sacrum, L5 vertebra, bilateral femoral heads, and L1 regions were contoured in the CT scans in which treatment planning was done. Sagittal cross-sectional images were taken advantage of while these regions were being contoured. ResultsBone mineral density was evaluated with CT and dual-energy X-ray absorptiometry before and after the treatment. The regions that have theoretically been exposed to irradiation, such as L5, sacrum, left to right femur were found to have significant difference in terms of bone density. According to CT evaluation, there was a significant decrease in bone intensity of L5, sacrum, left and right femurs. Dual-energy X-ray absorptiometry assessment revealed that the whole of the left femoral head, left femur neck and Ward's region were significantly affected by radiotherapy. However, there was no significant difference in the sacrum and L5 vertebra before and after radiotherapy. ConclusionMore accurate results could be achieved if the same study was conducted on a larger patient population, with a longer follow-up period. When the reduction in bone density is at maximum or a cure is likely in a long-term period, bone mineral density could be determined by measurements performed at regular intervals.

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)

To explore the molecular mechanism of kidney-tonifying and blood-activating method in the prevention and treatment of postmenopausal osteoporosis based on cAMP-PKA-CREB signaling pathway

Purpose: Based on the cAMP-PKA-CREB signaling pathway, the possible intervention mechanism of kidney-nourishing and blood-activating decoction in the prevention and treatment of postmenopausal osteoporosis was discussed, providing new experimental evidence for elucidating the mechanism of kidney-nourishing and blood-activating decoction in the treatment of osteoporosis Methods: 60 healthy SD rats, female, 12 weeks old, body weight (240 + 20)g, were randomly divided and numbered after weighing. A total of 5 groups: blank control group (n=10), model group (n=10), western medicine group (n=10), high-dose Chinese medicine group (n=10) (16g/Kg. D), low-dose Chinese medicine group (n=10) (8g/Kg).For the blank control group and the model group, the western drug alendronate sodium group was given daily dose of alendrine sodium suspension for 8 weeks while the standard feed was routinely fed, and the dosage of intragastric drug was 10 mL/kg. For the group with high and low dose of traditional Chinese medicine, the standard feed was continued to be fed while the anti-sparing bone prescription concentrate was given daily for 8 weeks.In addition to the normal group and the model group, the animals in each group were collected at week 9 according to the corresponding dose of perfusion, and the bone mass was measured by double energy X-ray, and sacrificed the next day. The femoral head was taken for basic studies such as histomorphology and RT-PCR. Results: After 8 weeks in the model group, western medicine group, high-dose Chinese medicine group and low-dose Chinese medicine group, bilateral femoral head appeared obvious necrosis, while there was no obvious change in the normal group. Compared with the normal group, the expressions of cAMP and PKA in the model group, the western medicine group, the high-dose group and the low-dose group were all increased to different degrees, while the expression of CREB was significantly down-regulated. The expression of the above genes in the three groups was significantly different from that in the normal group (P<0.05). After 8 weeks of intragastric administration, the femoral head of the model group was dark and rough, resulting in osteoporosis. The femoral head of the high dose group and the low dose group showed no obvious change in appearance. In the western medicine group, the color of the femoral head was more bright, and some of the color was darker, but the morphology did not change significantly. In the morphology of femoral head of rats, the femoral head of rats in the western medicine group was lighter in color, but the morphology did not change significantly. Compared with the normal group, there was no significant difference in the expression of cAMP, PKA and CREB in the four groups of bone tissue (P>0.05). However, the expression of PKA and CREB was down-regulated in both the Chinese medicine group and the western medicine group, and the expression of cAMP was up-regulated, which was significantly different from the model group (P<0.05). Conclusions: By regulating the cAMP-PKA-CREB signaling pathway, kidney-invigorating and blood-activating formula can intervene in postmenopausal osteoporosis, inhibit the activity of osteoclasts, and activate osteoblasts, so as to cause normal metabolism of bone regeneration and bone remodeling, and delay the occurrence of osteoporosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

ACC Research Agenda Conference 2019: Peer Reviewer Acknowledgments and Abstracts of Proceedings.

ACC Research Agenda Conference 2019: Peer Reviewer Acknowledgments and Abstracts of Proceedings.

Radiographic Analysis of Minimally Invasive Transforaminal Lumbar Interbody Fusion versus Conventional Open Surgery on Sagittal Lumbar-Pelvic Alignment for Degenerative Spondylolisthesis

To compare the impact of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with open posterior lumbar interbody fusion (PLIF) on sagittal lumbar-pelvic radiographic parameters for degenerative spondylolisthesis (DS). Of 48 patients with L4 single segmental DS, 25 underwent MIS-TLIF with Quadrant system and 23 underwent conventional open PLIF. Comparisons of data from the preoperative and final follow-up standing lateral lumbar x-rays, with the bilateral femoral heads, of the 2 groups were conducted using the following parameters: slip percentage (SP), lumbar lordosis (LL), pelvic incidence, pelvic tilt (PT), sacral slope, lumbosacral angle, slip angle (SA), and the L1 axis and S1 distance (LASD). The slip reduction rate (ΔSP) in the OPEN group was significantly higher than in the MIS group (67 ± 34% vs. 37 ± 51%, P= 0.018). The change of SA (ΔSA) in the OPEN group was significantly higher than in the MIS group (3 ± 7° vs. -3 ± 5°, P= 0.003). The change of LASD (ΔLASD) in the OPEN group was significantly lower than in the MIS group (-4 ± 15 mm vs. 4 ± 9 mm, P= 0.033). There were positive correlations between the preoperative SP and LASD, and ΔSA and the change of LL (ΔLL), and a negative correlation between ΔLL and the change of PT (ΔPT). For low-grade DS, open PLIF has a higher rate of slip reduction compared to MIS-TLIF, and significantly reduces LASD, therefore, it is more conducive to improving lumbar sagittal balance.

Risk factors for osteonecrosis severity among Egyptian systemic lupus erythematosus patients: Magnetic resonance imaging (MRI) staging

Aim of the workTo determine the risk factors of bilateral and severe (advanced) osteonecrosis femoral head (ONFH) as assessed by magnetic resonance imaging (MRI) staging in Egyptian SLE patients. Patients and methodsSixty SLE patients were studied and subdivided into two groups according to the presence or absence of symptomatic osteonecrosis. Full medical history, musculoskeletal examination, laboratory and serologic tests were done to all patients. SLE disease activity index (SLEDAI), systemic lupus international collaboration clinics damage index (SLICC/DI), health assessment questionairre (HAQ) disability index and the visual analogue scale (VAS-pain) were assessed. 30 patients with symptomatic ONFH were identified and staged by MRI according to Ficat and Arletclassification. Dual energy x-ray absorptiometry (DEXA) scan was performed. ResultsThe mean age at-onset of patients with ONFH was significantly lower than those without (20.7 ± 5.9 vs 30.4 ± 7.9 years; p < 0.0001) with comparable genders (F:M 29:1 vs 26:4; p = 0.16). SLEDAI, SLICC/DI, HAQ were significantly increased (p = 0.001 each) and DEXA reduced (p = 0.02) in those with ONFH. Predictors of ONFH severity included the presence of serositis (p = 0.005), arthritis (p = 0.02), gastrointestinal (GI) manifestations (p = 0.005), cardiac involvement (p = 0.049), diabetes (p = 0.01), elevated creatinine (0.008), urine sediments (p = 0.006), VAS-pain (p = 0.005), steroids (p = 0.015) and absence of hydroxychloroquine (HCQ) intake (p = 0.045). Risk factors of bilateral ONFH were the presence of serositis, nephritis, increased SLICC/DI and increased VAS-pain (p = 0.02, p = 0.03, p = 0.009 and p = 0.008, respectively). ConclusionNephritis, serositis, GI involvement, arthritis, steroids are key predictors for advanced ONFH while HCQ was protective. Risk factors for bilateral ONFH were serositis, nephritis, increased damage-index and VAS-pain.

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.

Effect and mechanisms of vitamin E on early steroid-induced avascular necrosis of femoral head in rats

To investigate the possibility of mitochondria-dependent apoptosis as a mechanism of early steroid-induced avascular necrosis of femoral head (SANFH) in rats and vitamin E as a possible prevention strategy. Seventy-two male Sprague Dawley rats were randomly divided into control group, model group, and intervention group, with 24 rats in each group. The rats in control group were not treated as normal control. The rats in model group and intervention group were established early SANFH models by lipopolysaccharide combined with methylprednisolone injection. At the same time, the rats in intervention group were injected with vitamin E (40 mg/kg) every day for 7 days. At 2, 4, and 8 weeks after the final injection, the bilateral femoral heads were harvested and observed by HE staining, TUNEL assay, immunohistochemical staining, and Western blot. The rate of empty lacunae, apoptotic index, and the expressions of Caspase-9, Caspase-3, and cytochrome-c (Cyt-c) proteins were calculated. According to histological staining, there were significant differences in the rate of empty lacunae between intervention group and control group at 8 weeks ( P<0.05) and between intervention group and model group at 4 and 8 weeks ( P<0.05). The apoptotic index of intervention group was significantly lower than that of model group at each time point ( P<0.05). And there was significant difference between the intervention group and the control group at 8 weeks ( P<0.05). According to immunohistochemistry staining and Western blot, the expressions of Cyt-c, Caspase-9, and Caspase-3 all significantly decreased in intervention group than those in model group at each time point ( P<0.05); and the differences were significant between intervention group and control group at 8 weeks ( P<0.05). Vitamin E can delay the progression of early SANFH by reducing mitochondrial dependent osteocyte apoptosis.

Progression of idiopathic thoracic or thoracolumbar scoliosis and pelvic obliquity in adolescent patients with and without limb length discrepancy

ΒackgroundBoth limb length inequality and scoliosis are associated with pelvic obliquity.MethodsThis is an observational study of adolescents with growth potential presenting for evaluation of thoracic or thoracolumbar idiopathic scoliosis at an outpatient pediatric orthopedic clinic. Patients were evaluated for limb length discrepancy (LLD) (using bilateral femoral head height difference), pelvic obliquity (using bilateral iliac crest height difference and sacral takeoff angle), and scoliotic curve (using Cobb angle and rotation) on full spine standing radiographs. The same radiographic parameters were measured at a follow-up visit at least 2 years later.ResultsSeventy-three consecutive patients with a mean (SD) age of 13.3 (0.2) years at initial examination were included in the study. Scoliosis (major curve Cobb angle ≥ 10°) was confirmed in all 73 patients, pelvic obliquity (iliac crest height difference > 1 cm or sacral takeoff angle > 5°) appeared in 23 (31.5%) patients with scoliosis, and LLD (> 1 cm femoral head height difference) was identified in 6 (8.2%) patients with scoliosis and pelvic obliquity. At a subsequent visit, a mean of 2.8 (range 2–5.8) years later, no significant change (p > 0.05) in limb length inequality was observed but a statistically significant increase (p < 0.05) in scoliotic and pelvic deformity parameters was found.ConclusionsIn adolescent patient population with thoracic or thoracolumbar scoliosis, the anisomelia remains stable with growth but both the scoliotic deformity and pelvic obliquity progress.Trial registrationMGH no 2012-P-000774/1

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

A case of bilateral revision total knee arthroplasty using distal femoral allograft\u2013prosthesis composite and femoral head allografting at the tibial site with a varus-valgus constrained prosthesis: ten-year follow up

BackgroundWe report the successful use of allograft–prosthesis composite (APC) and structural femoral head allografting in the bilateral reconstruction of large femoral and tibial uncontained defects during revision total knee arthroplasty (RTKA).Case presentationA 67-year-old female with degenerative arthritis underwent bilateral total knee arthroplasty (TKA) using the Press Fit Condylar (PFC) modular knee system at our clinic in March, 1996. At 8 years postoperatively, the patient presented with painful, bilateral varus knees, with swelling, limited passive range of motion (ROM), and severe instability. We treated to reconstruct both knee using a femoral head allograft at the tibial site, a structural distal femoral allograft at the femoral site, and a varus-valgus constrained (VVC) prosthesis with cement. At the 10-year follow up, we found no infection, graft failure, loosening of implants, in spite of using massive bilateral structural femoral head allografts in RTKA.ConclusionThe use of APC enabled a stable and durable reconstruction in this uncommon presentation with large femoral bone deficiencies encountered during a RTKA.