Bilateral Osteonecrosis Of Femoral Head Research Articles

Femoral neck fracture after femoral head necrosis: a case report and review of the literature

IntroductionPathological fractures of the femoral neck caused by necrosis of the femoral head are extremely rare. Here, we report a rare case of bilateral femoral head osteonecrosis extending to the femoral neck, with bilateral pathological fractures of the femoral neck occurring within a short period of time.Case reportA 65-year-old male with a 25-year history of daily consumption of 750 ml of liquor, presented with right hip pain after labor for 1 month. He subsequently sustained a right femoral neck fracture without trauma and underwent a right total hip arthroplasty. Two months later, he suffered a non-traumatic left femoral neck fracture and underwent a left total hip arthroplasty. Histopathological examination revealed osteonecrosis of the femoral head and neck, along with the presence of osteoclasts and granulomatous inflammation. Bone mineral density testing also showed osteoporosis. The bilateral femoral neck fractures were ruled out to be caused by any other pathological factors.DiscussionThis is the first report of pathological fractures of the bilateral femoral neck caused by femoral head necrosis. During the literature review process, we found that this case conforms to the histological characteristics of rapidly destructive hip disease and analyzed the etiology of femoral head necrosis and the pathogenesis of femoral neck fractures.

THU470 Blood - Bone Connection? A Case Of A Young Woman With Bilateral Hip Osteonecrosis And Prothrombin Mutation

Abstract Disclosure: A. Sliwinska: None. C. Vanek: None. Introduction: Osteonecrosis of the femoral head (ONFH) is a localized bone disease responsible for 10% of total hip replacements in the United States. Although the condition is a separate entity from osteoporosis, it may co-occur representing underlying systemic bone disease. Many risk factors (steroids, trauma, infections, thrombophilia, blood cell dyscrasias) can predispose to ONFH, therefore, diligent evaluation is required to reveal the underlying cause. There are no FDA approved therapies. Here, we present a case of young woman with bilateral osteonecrosis of femoral head who was found to have prothrombin gene mutation, severe osteoporosis, and was successfully treated with PTH analog therapy with abaloparatide. Case Description: 33-year-old Asian female with no past medical history presented to the Endocrinology clinic for a metabolic bone disease assessment. Two years prior, she developed progressive bilateral hip pain which prompted radiographic evaluation, discovering bilateral ONFH. She was managed non-surgically with a 6-month trial of oral alendronate. Worsening pain prompted left hip decompression surgery with stem cell transfer. Patient had no history of fragility fractures nor family history of bone disease. A bone density revealed Z scores of -3.9 and -3.5 in lumbar spine and total hip, respectively. She was taking 2000 IU vitamin D3 and 600 mg of elemental calcium daily. Her blood tests revealed normal basic metabolic panel, normal complete blood count and liver function tests. Calcium was 9.0 mg/dl (ref:8.6-10.2), albumin 4.6 mg/dl (3.5-4.7 mg/dl), phosphorus 4.0 mg/dl (2.4-4.7 mg/dl), PTH of 28 pg/ml (18-88 pg/ml), Vitamin D 25-hydroxy 41.3 ng/ml (30-80 ng/ml), and TSH was 1.66 mIU/L (0.39-4.17 mIU/L). Patient had an infectious, metabolic and rheumatological work-up that was negative. A thrombosis workup showed a heterozygous prothrombin gene (G20210A) mutation. Factor V Leiden mutation was negative. Repeat Hip MRI showed progression of her ONFH with marked bone marrow edema in femoral head bilaterally. Patient was then started on abaloparatide. After 6 months, hip MRI showed marked improvement with no bone marrow edema. Discussion: Osteonecrosis of the femoral head is a complex disease that can affect young individuals. Bilateral ONFH suggests systemic disease and a thorough work-up is necessary. Although the exact mechanism is unclear, it has been hypothesized that thrombin plays a role in bone homeostasis therefore hematologic disorders may predispose patients to both ONFH and osteoporosis. Medical treatment of ONFH, including bisphosphonates, statins, or anticoagulants, have been suggested. Recently the PTH analog, teriparatide, has shown promising results and found to be beneficial in treating osteonecrosis. Our case highlights importance of thorough work-up for patients with bilateral ONFH and successful use of anabolic agent in this population. Presentation: Thursday, June 15, 2023

P18 A case report on Atypical Polymyalgia Rheumatica in Young Adult

Introduction/BackgroundPolymyalgia Rheumatica is a common inflammatory condition after the age of 50 years. It typically presents with shoulder, neck and pelvic pain and stiffness associated with raised inflammatory markers. We report a case of Polymyalgia Rheumatica in a young male of 40 years in which clinical presentation was not typical.Description/MethodA 40-year-old male manager in a retail shop was reviewed in Rheumatology Outpatient clinic with a few months history of back and pelvic pain with progressively worsening early morning stiffness for upto 40 minutes associated with marked fatigue ability. There was also pain in the right shoulder following a trauma causing rotator cuff tear shown on MRI done a year ago. His CRP was 19 and ESR 52. Initial assessment was inflammatory Axial Spondyloarthropathy.MRI of spine and SI joints as discussed in radiology MDT didn’t show inflammatory changes in the spine or SI joints. It showed bilateral Osteonecrosis of Femoral heads and ill-defined oedema in left acetabulum. A repeat MRI and CT of pelvis showed sclerotic lesion in left Acetabulum. The patient was discussed in bone and soft tissue tumour MDT with conclusion of non-malignant lesion without requiring biopsy and seen by orthopaedics.The pain progressed to involve left shoulder as well despite regular use of NSAIDs. The stiffness deteriorated and became generalised for up to 2 hours. The fatigability also got worse with some interference in his Job. CRP readings were 19, 19, 25 and 20 whereas ESR was 52, 48, 32 and 40 with an interval of a month each.Multiple other investigations including WCC, Hb, U& Es, LFTs, TSH, CK, bone profile, RF, anti CCP, ANA, ENA, ANCA, Serum protein electrophoresis, Myeloma screen, urine analysis, XR chest and ECG were normal.He went on to have PET CT that showed increased uptake suggestive of arthritis in both shoulders, sternoclavicular joints, 1st Costochondral joint, left hip and posterior spinal ligament. The findings were discussed in Radiology MDT again with a conclusion of diagnosis of Polymyalgia Rheumatica based on the distribution of joints involved.Discussion/ResultsThe patient was started on Prednisolone at a dose of 20mg daily. His symptoms improved within 3 to 4 days of start of Prednisolone. Inflammatory markers also improved were checked after 4 weeks with CRP 4 and ESR 18 and they remained normal in two subsequent readings after two and three months. He is currently on tapering dose of Prednisolone without recurrence of symptoms as well as rise in inflammatory markers.Pattern of joint involvement on PET CT and dramatic response to steroids confirmed the diagnosis of PMR.Key learning points/ConclusionAlthough PMR is most commonly seen in adults over 50 years but it can present in young adults like in this patient.Because of young age and atypical presentation mutiple investigations including PET CT was required to reach to the diagnosis of PMR that otherwise is made based on clinical presentation associated with raised raised inflammatory markers.Osteonecrosis of Femoral heads in the absence of any other positive investigation was thought most likely secondary to Inflammation that again is not very common presentation of PMR.A long term follow up is required for this patient to monitor the response of reducing and then stopping of steroids.

Bilateral femoral head osteonecrosis in a patient with metastatic breast cancer receiving long‑term zoledronic acid treatment: A case report

Bone-modifying agents (BMAs), including bisphosphonate and anti-receptor activator of NF-κB ligand (RANKL) antibodies, are effective in treating bone metastases. The present study is a case report on the efficacy and side effects of long-term treatment with zoledronic acid, a BMA, in a 57-year-old woman. The patient was diagnosed with concurrent stage IV triple-negative breast cancer and stage II colon cancer. The patient experienced complete remission of both these cancers following chemotherapy, zoledronic acid treatment and irradiation for breast cancer and surgery for colon cancer. The patient received long-term zoledronic acid treatment and has survived >7 years after her initial diagnosis. The patient subsequently reported bilateral hip pain that was diagnosed as osteonecrosis of the femoral head, after the presence of bone metastases was ruled out using magnetic resonance imaging. The patient underwent bilateral artificial hip joint replacements. After orthopedic surgery, the multiple distant metastases, including a brain metastasis, remained in complete remission. It is well established that BMAs, such as zoledronic acid, increase the risk of osteonecrosis of the jaw, but it is not well understood if they can increase this risk in other anatomical locations. The findings of the present case study suggested that while long-term use of BMAs may be effective in managing bone metastases, it may increase the risk of osteonecrosis in anatomical locations other than the jaw.

Single Stage Simultaneous Core Decompression for Ficat Stage I and II Bilateral Femoral Head Osteonecrosis among Hip Surgeries done in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Osteonecrosis of femoral head is a disease affecting young individuals and often occurs in bilateral hips. The purpose of this study is to find out the prevalence of single stage simultaneous core decompression for Ficat stage I and II bilateral femoral head osteonecrosis among total hip surgeries done in a tertiary care center. A descriptive cross-sectional study was conducted at a tertiary care trauma centre from April 2017 and March 2020. Ethical approval was obtained from the Institutional Review Committee prior to data collection (Reference no: 673/2077/78). Convenience sampling was done. Patients undergoing hip surgeries were included in the study. Patients with missing data were excluded. Patients operated upto Ficat Stage IIb femoral head osteonecrosis were followed up. Data was analysed using the Statistical Package for Social Sciences version 22.0. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data. Out of 916 patients who underwent hip surgeries, 12 (1.31%) (0.57-2.04 at 95% Confidence Interval) underwent single stage simultaneous core decompression. Idiopathic cause in 6 (50%) and prolonged corticosteroid usage in 4 (33.33%) were the leading causes. Twelve (50%) of the treated hips were in Ficat stage IIa. At the end of one year, of the 11 patients who followed up, 12 (54.5%) hips had a good Harris hip outcome. Our study showed that a small proportion of hip surgeries were single stage simultaneous bilateral core decompression for osteonecrosis of femoral head in our setting. Our findings were similar to studies done internationally with a very low complication rate.

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.

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.

Bilateral Osteonecrosis of Femoral Head in Sickle Cell Disease: Salvage by Early Surgical Treatment in Single Sitting

Bilateral Osteonecrosis of Femoral Head in Sickle Cell Disease: Salvage by Early Surgical Treatment in Single Sitting

Bilateral femoral head osteonecrosis due to cyclosporine therapy in aplastic anemia

Bilateral femoral head osteonecrosis due to cyclosporine therapy in aplastic anemia

Case report: primary osteonecrosis associated with thrombophilia-hypofibrinolysis and worsened by testosterone therapy

BackgroundFamilial and acquired thrombophilia are often etiologic for idiopathic hip and jaw osteonecrosis (ON), and testosterone therapy (TT) can interact with thrombophilia, worsening ON.Case presentationCase 1: A 62-year-old Caucasian male (previous deep venous thrombosis), on warfarin 1 year for atrial fibrillation (AF), had non-specific right hip-abdominal pain for 2 years. CT scan revealed bilateral femoral head ON without collapse. Coagulation studies revealed Factor V Leiden (FVL) heterozygosity, 4G/4G plasminogen activator inhibitor (PAI) homozygosity, high anti-cardiolipin (ACLA) IgM antibodies, and endothelial nitric oxide (NO) synthase (eNOS) T786C homozygosity (reduced conversion of L-arginine to NO, required for bone health). Apixaban 5 mg twice daily was substituted for warfarin; and L-arginine 9 g/day was started to increase NO. On Apixaban for 8 months, he became asymptomatic. Case 2: A 32-year-old hypogonadal Caucasian male had 10 years of unexplained tooth loss, progressing to primary jaw ON with cavitation 8 months after starting TT gel 50 mg/day. Coagulation studies revealed FVL heterozygosity, PAI 4G/4G homozygosity, and the lupus anticoagulant. TT was discontinued. Jaw pain was sharply reduced within 2 months.ConclusionsIdiopathic ON, often caused by thrombophilia-hypofibrinolysis, is worsened by TT, and its progression may be slowed or stopped by discontinuation of TT and, thereafter, anticoagulation. Recognition of thrombophilia-hypofibrinolysis before joint collapse facilitates anticoagulation which may stop ON, preserving joints.

A histomorphometric study of necrotic femoral head in rabbits treated with extracorporeal shock waves.

[Purpose] This study aimed to determine the effectiveness and mechanisms of extracorporeal shock wave therapy in the treatment of femoral head osteonecrosis. [Subjects and Methods] Histomorphometric analysis of necrotic femoral head in rabbits treated with shock waves was performed. Bilateral osteonecrosis of femoral heads was induced with methylprednisolone and lipopolysaccharide in eight rabbits. The left limb (study side) received shock waves to the femoral head. The right limb (control side) received no shock waves. Biopsies of the femoral heads were performed at 12 weeks after shock wave therapy. [Results] Necrotic femoral heads treated with shock waves, compared with controls, had higher bone volume per tissue volume, trabecular thickness, trabecular number, osteoblast surface/bone surface, osteoid surface/bone surface, osteoid thickness, mineralizing surface/bone surface, mineralizing apposition rate, and bone formation rate. However, trabecular separation was lower in shock wave-treated femoral heads than in controls. Eroded surface/bone surface and osteoclast surface/bone surface did not differ significantly between groups. [Conclusion] The bone mass of necrotic femoral heads treated with shock waves increases. Extracorporeal shock wave may promote bone repair in necrotic femoral heads through the proliferation and activation of osteoblasts.

Oncogenic Osteomalacia Caused by a Phosphaturic Mesenchymal Tumor of the Proximal Femur

Background: Oncogenic osteomalacia is a rare paraneoplastic syndrome, with only about 100 reported cases in the literature. It is characterized by renal phosphate wasting, hypophosphatemia, low functional vitamin D, normocalcemia, normal PTH, and increased levels of alkaline phosphatase. The majority of oncogenic osteomalacia is usually caused by phosphaturic mesenchymal tumors of mixed connective tissue. Case Description: In this case report, the authors present a case of oncogenic osteomalacia in a patient who initially presented with hip pain for bilateral femoral head osteonecrosis and was noted to have multiple insufficiency fractures of unknown cause. The patient was eventually worked up with a PET/CT scan which showed a 2cm tumor in his right proximal femur. A core biopsy of this lesion revealed it was a mesenchymal tumor. Given the patient’s osteonecrosis of the bilateral proximal femurs, we chose to treat him with a right total hip arthroplasty. As part of this surgery requires making a femoral neck cut and removing the head and neck of the femur, the femoral lesion was completely excised, and this led to resolution of his hypophosphatemia, and improvement in his symptoms.Literature Review: There have been only three case reports of a similar lesion in the proximal femur causing oncogenic osteomalacia in the literature, and each was treated differently with varying outcomes.Clinical Relevance: Although an extremely rare disease, clinicians and pathologists should be aware of oncogenic osteomalacia and phosphaturic mesenchymal tumors as a cause of unexplained insufficiency fractures in patients with hypophosphatemia.

Prevalence of genetic risk factors related with thrombophilia and hypofibrinolysis in patients with osteonecrosis of the femoral head in Poland

BackgroundThe etiology of osteonecrosis of femoral head (ONFH) has not been fully elucidated. Increased intravascular coagulation and/or hypofibrinolysis have been proposed as pathogenic mechanisms. Previous reports demonstrated significant association between incidence of ONFH and polymorphisms of genes related with thrombophilia especially in Caucasian subjects. The aim of our study was to evaluate the relationship between genetic mutations leading to coagulation disorders and ONFH in Polish patients.MethodsWe have investigated the frequencies of four markers among 68 unrelated individuals with clinically and radiographically documented ONFH and among 100 healthy unrelated blood donors in Eastern part of Poland. The three genes were involved in thrombophilia: factor V Leiden (G1691A), prothrombin (G20210A), Methylenetetrahydrofolate Reductase (MTHFR C677T) and one in hypofibrinolysis: Tissue Plasminogen Activator (PLAT TPA25 I/D). The samples were genotyped with polymerase chain reaction followed by restriction enzyme analysis for the restriction fragment length polymorphisms. The allele and genotype frequencies were analyzed in the relation to ONFH etiology (idiopathic and secondary), gender, age (patients younger or older than 50 years) and the number of affected joints (unilateral or bilateral ONFH).ResultsNo significant difference in allele frequencies between patients and control groups were observed in genes involved in thrombophilia. We have found a statistically significant increased frequency of D allele of PLAT TPA 25 I/D polymorphism between the entire group of patients with ONFH and controls (p=0,026, OR=1,54, CI 0,99-2,4). D allele frequency was also significantly increased in patients with primary ONFH (p=0,009, OR=1,81 CI 1,1-3,01), in males (p= 0,013; OR 1,74; 95% CIs 1,08-2,78), patients older than 50 years (p= 0,018, OR= 2,04; 95% CIs 1,09-3,82) and in cases with bilateral ONFH (p= 0,01; OR= 1,92; 95% CIs 1,13-3,27) (Table 9). The differences in DD homozygous genotype frequency were statistically significant for patients with idiopathic ONFH compared with control group (p=0,023, OR=2,75, CI 0,99-7,9) and in cases of bilateral ONFH (p=0,034; OR 3,12; 95% CIs 1,06-9,18) (Table 10). The frequencies of ID heterozygous genotype were statistically significantly higher in entire group of patients with ONFH (p=0,004 OR 2,71; 95% CIs 1,32-5,57), idiopathic ONFH (p= 0,01; OR 2,91; 95% CIs 1,24-6,87), males (p=0,0007; OR 3,75; 95% CIs 1,67-8,42), patients older than 50 years (p=0,001; OR 6,89; 95% CIs 1,87-25,84) and in cases with bilateral ONFH (p=0,009; OR 3,19; 95% CIs 1,26-8,03).ConclusionThe results suggest that inherited hypofibrinolysis is a risk factor of idiopathic ONFH in Polish population.

The effect of core decompression on local expression of BMP-2, PPAR-γ and bone regeneration in the steroid-induced femoral head osteonecrosis

BackgroundTo investigate the efficacy of the sole core decompression surgery for the treatment of steroid-induced femoral head osteonecrosis.MethodsThe model was established by administration of steroids in combination with horse serum. The rabbits with bilateral femoral head osteonecrosis were randomly selected to do the one side of core decompression. The other side was used as the sham. Quantitative RT-PCR and western blot techniques were used to measure the local expression of BMP-2 and PPAR-γ. Bone tissues from control and operation groups were histologically analyzed by H&E staining. The comparisons of the local expression of BMP-2 and PPAR-γ and the bone regeneration were further analyzed between different groups at each time point.ResultsThe expression of BMP-2 in the osteonecrosis femoral head with or without decompression was significantly lower than that in normal animals. BMP-2 expression both showed the decreasing trend with the increased post-operation time. No significant difference of BMP-2 expression occurred between femoral head osteonecrosis with and without decompression. The PPAR-γ expression in the femoral head osteonecrosis with and without core decompression both was significantly higher than that in control. Its expression pattern showed a significantly increased trend with increased the post-operation time. However, there was no significant difference of PPAR-γ expression between the femoral head osteonecrosis with and without decompression at each time point. Histopathological analysis revealed that new trabecular bone and a large number of osteoblasts were observed in the steroid-induced femoral head osteonecrosis with lateral decompression at 8 weeks after surgery, but there still existed trabecular bone fractures and bone necrosis.ConclusionsAlthough decompression takes partial effect in promoting bone regeneration in the early treatment of femoral head osteonecrosis, such an effect does not significantly improve or reverse the pathological changes of femoral head necrosis. Thus, the long-term effect of core decompression in the treatment of steroid-induced femoral head osteonecrosis is not satisfactory.

Sorafenib-Induced Bilateral Osteonecrosis of Femoral Heads

A 53-year-old man diagnosed with hepatocellular carcinoma(HCC) occurring in post–hepatitic C cirrhosis was first treated withright hepatectomy in May 2004. Because of cytologically proven re-currence as mediastinal and vertebral metastases, he was treated withchemotherapycombininggemcitabineandoxaliplatinefromDecem-ber 2004 to January 2005. The bone lesions extended and becamepainful, so the patient received analgesic lombar radiotherapy in Sep-tember 2005 and cimentoplasty in September 2007. In addition, sor-afenib (Nexavar; Bayer Pharmaceuticals Group, Montville, NJ) at adosage of 800 mg per day was started in February 2008. Initial serumlevel of alpha fetoprotein (AFP) was 180 ng/mL. Ten months afterstarting the treatment, the patient suffered from hip pain when walk-ing. Physical examination was normal except for pain on active andpassive leg mobilization. Blood tests were unremarkable, except forhepaticcytolysisrelatedtoongoinghepatitisC.TheserumlevelofAFPwas 600 ng/mL. Magnetic resonance imaging of the femoral headsshowedbilateralosteonecrosis(Fig1);asubchondrallineofdemarca-tion bounded a low signal intensity on T1- and T2-weighted images,corresponding to the necrotic area. There were bone marrow edemaand subchondral fissures. The patient did not receive (at that time orpreviously)corticosteroidorbiphosphonatetreatment.Sorafenibwasstopped and we declared this adverse event to the pharmacovigilancecenter of Lyon, France, in February 2009 (number LY20090440).SorafenibisanoralmultikinaseinhibitorthatinhibitsRafserine/threonine kinases and tyrosine kinase receptors involved in tumorgrowth and angiogenesis. It has demonstrated preclinical and clin-ical activity in several tumor types, including advanced HCC.

A case of SLE with bilateral osteonecrosis of femoral heads and bone infarct in distal of femur

Osteonecrosis of bone is a major cause of morbidity in lupus patients, and is most common in the femoral head. It has been reported in wide range of patients (2-30%). In different studies presence of arthritis, Raynaud phenomenon, vasculitis, pleuritis, antiphospholipid and other factors were associated with this occurrence. Bone infarcts were also associated with these factors. We report a 21-year-old patient who was diagnosed as SLE about 3 years ago. When the patient was stable with hydroxychloroquine and prednisolone referred to rheumatologic clinic for mechanical knee pain, in evaluation she had bone infarct in distal femur. Two months later she came back with bilateral hip pain, and in evaluation she had bilateral osteonecrosis of femoral heads. There are many reports of femoral head osteonecrosis in lupus patients, and also one report of multiple bone infarct and pain in SLE, but we did not find any report of these two phenomena together in a patient whose disease was controlled and she took minimum of steroid and DMARD in the about 2-month follow-up, and this was very interesting for us.

Bone Scan Appearance of Bilateral Femoral Head Osteonecrosis Secondary to Polyostotic Fibrous Dysplasia.

Bone Scan Appearance of Bilateral Femoral Head Osteonecrosis Secondary to Polyostotic Fibrous Dysplasia.

One-stage hip arthroplasty and bone grafting for bilateral femoral head osteonecrosis.

One-stage hip arthroplasty and contralateral core decompression with bone grafting were performed for 30 patients with bilateral femoral head osteonecrosis between April 2002 and June 2005. The treatment course, clinical and radiographic outcomes, and medical costs were compared with another 30 age-, gender-, etiology-, and disease extent-matched patients undergoing two-stage treatment during the same period. The two groups had similar clinical data and few complications. Total hospital stay and associated costs were reduced for patients who had one-stage treatment. These patients also returned to work faster (6.0 versus 10.8 months). At an average followup of 46 months, progression to greater than 2 mm of collapse of the salvaged femoral head was observed in seven patients (23%) who had one-stage treatment and 14 patients (47%) who had two-stage treatment. Conversion to hip arthroplasty was performed in five patients (17%) in the one-stage group and 12 patients (40%) in the two-stage group. A special group of patients with bilateral osteonecrosis of the femoral head seemed to benefit from one-stage hip arthroplasty and contralateral core decompression with bone grafting and had better survival of the salvaged femoral head. One-stage hip arthroplasty and core decompression with bone grafting proved to be a cost-effective method that did not increase perioperative morbidity. Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

両側に骨切り術を行った大腿骨頭壊死症例

両側に骨切り術を行った大腿骨頭壊死症例

Correlation between baseline femoral neck marrow status and the development of femoral head osteonecrosis in corticosteroid-treated patients: A longitudinal study by MR imaging

Objective To test the hypothesis that the development of corticosteroid (CS)-associated femoral head osteonecrosis (ON) is influenced by baseline femoral neck marrow status. Patients and methods The population consisted of 20 untreated patients with a newly diagnosed rheumatic disease in whom a standardized CS regimen was planned. Before CS treatment, baseline femoral neck marrow status was determined by magnetic resonance (MR) imaging on T1-weighted images (proportion of surface area of femoral neck and intertrochanteric area occupied by fatty marrow; index of marrow conversion [IMC]) and on a quantitative MR sequence (bulk T1 values of femoral head and neck). The presence of ON was assessed by coronal T1-weighted MR images of the hips at 6 and 12 months. Results None of the patients suffered from ON at baseline. Four patients (20%) developed bilateral femoral head ON at 6 months. The mean percentage of fat marrow in the femoral neck before treatment was significantly higher in ON-positive than in ON-negative patients ( p = 0.0025). The mean baseline femoral neck IMC value, which parallels the degree of red to yellow marrow conversion, was higher in ON-positive than in ON-negative patients ( p = 0.089). The mean baseline bulk T1 value of the femoral neck (but not of the femoral head), which inversely correlates with the amount of fat marrow, was significantly shorter in ON-positive than in ON-negative patients ( p = 0.0298). Conclusion The development of CS-associated femoral head ON is correlated with a high fat content in the proximal femur before CS therapy.