Bilateral Osteonecrosis Of The Femoral Head Research Articles

Bilateral corticosteroid-induced osteonecrosis of the femoral head detected at a 6-week interval.

Introduction Corticosteroid-induced osteonecrosis of the femoral head (ONFH) often affects both femoral heads. Such bilateral ONFH cases are generally detected concurrently on magnetic resonance imaging (MRI). On the other hand, in unilateral cases, it is rare that contralateral ONFH is subsequently detected. We herein report a case in which bilateral ONFH was detected in both femoral heads by repeated MRI examination at an interval of 6 weeks.Case descriptionA 34-year-old man with purpura nephritis was started on corticosteroid therapy with prednisolone at 30 mg/day. Eight months after the initiation of corticosteroid therapy, he complained of left hip pain with no antecedent triggering activity. MRI obtained 8.5 months after the initiation of corticosteroid therapy showed the findings of osteonecrosis of the left femoral head, while no abnormalities were detected in the right femoral head. On the second MRI obtained 10 months after the initiation of corticosteroid treatment, however, osteonecrosis of the right femoral head was newly detected without an increase of the corticosteroid dose.ConclusionsThis case may indicate that corticosteroid-induced bilateral ONFH do not always develop at the same time.

Alcohol-associated osteonecrosis of the femoral head with subsequent development in the contralateral hip: A report of two cases

Although the pathogenesis of non-traumatic osteonecrosis of the femoral head (ONFH) has not been clarified, high-dose oral corticosteroid therapy and heavy consumption of alcohol have been associated with its occurrence [1e3]. Epidemiological surveys in Japan have found that 34% of ONFH patients have a history of heavy alcohol consumption [1]. The necrotic area of ONFH is determinedwhen it occurs, and the possibility of necrotic area extension is extremely low even if the patient continues taking oral corticosteroids or consuming large quantities of alcohol. The probability of ONFH occurring in both femoral heads is 50e80% [4], with bilateral ONFH thought to occur at almost the same time. Patients with unilateral ONFH rarely develop new ONFH in the contralateral hip. To our knowledge, only two previous case reports have described the occurrence of new ONFH in the contralateral hip: one with alcohol associated ONFH [5] and the other accompanying an increased dosage of corticosteroid [6]. This report describes two patients with alcoholassociated ONFH who developed ONFH of the contralateral hip following treatment of the first side. The patients and their families were informed that data from the cases would be submitted for publication, and gave their consent.

One-sided hip-preserving and concurrent contralateral total hip arthroplasty for the treatment of bilateral osteonecrosis of the femoral head in different stages: short-medium term outcomes

BackgroundWe aimed to evaluate the clinical and radiological short-medium term outcomes for the treatment of bilateral osteonecrosis of the femoral head (ONFH) with hip-preserving surgery of core decompression followed by tightly impaction bone grafting combining with non-vascularized fibular allografting in one hip and concurrent one-stage total hip arthroplasty (THA) in the contralateral side. We hypothesized the aforementioned surgery showed benefits of protecting the preserved hip from collapsing and thereafter THA was delayed or avoided.MethodsWe retrospectively reviewed a consecutive series of 18 non-traumatic bilateral ONFH patients (36 hips) who had undergone previous mentioned surgeries between July 2004 and June 2013. Preoperative and the last follow-up Harris Hip Score (HHS) and Visual Analogue Scale (VAS) Score were obtained for clinical outcomes evaluation and X-rays of antero-posterior and frog-leg lateral views of bilateral hips were compared for radiological outcomes assessment.ResultsAll patients were telephone contacted for out-patient clinic return visit at an average follow-up time of 53.3 months (ranged from 20 months to 107 months). Of the 18 patients (15 men and 3 women), there were 5 patients were diagnosed preoperative IIB stages according to classification of the Association Research Circulation Osseuse classification (ARCO) and the remaining 13 patients were in ARCO IIIC stages. The mean age of the included patients was 40.7 years (range from 22 to 59 years). No age and followed-up time difference existed in genders. The postoperative HHS were 83.8 ± 17.9 points, and it revealed statistical significance when compared to preoperative 61.6 ± 17.0 points (p < 0.05). The VAS scores were reduced from preoperative 6.2 ± 2.0 points to postoperative 2.8 ± 2.3 points, which also manifested outcomes significance (p < 0.05). From radiological aspects, 14 patients acquired well repairmen of the necrotic areas of the femoral head. However, the other 4 patients ultimately suffered femoral head collapse, and the severe pain was gotten rid of after THA surgeries were performed.ConclusionsThe un-collapsed hip can achieve biological stability and sufficient blood supply through the hip-preserving surgery and obtain longtime repairmen of the necrotic bone as well as early non-weight-bearing function training, which benefits from distributing the whole body weight load to the hip of one-stage THA. Consequently, we recommend this sort of surgery for clinical practice trial when faced bilateral ONFH in different stages though longer time follow-up and larger samples are essentially needed to address its efficacy.

Prevalence of clinical anxiety, clinical depression and associated risk factors in chinese young and middle-aged patients with osteonecrosis of the femoral head.

ObjectiveTo investigate the prevalence of clinical anxiety and clinical depression in Chinese young and mid-aged patients with osteonecrosis of the femoral head (ONFH) and to analyze their potential risk factors.MethodsTwo hundred and sixteen Chinese patients with ONFH were consecutively enrolled in this cross-sectional study from January 2010 to December 2010. The Zung self-rating anxiety scale (SAS) and the Zung self-rating depression scale (SDS) were used to assess the prevalence of clinical anxiety and clinical depression. An additional questionnaire containing seventeen items of potential risk factors was completed by all patients. Binary logistic regression analysis was employed to reveal potential risk factors of anxiety and depression.ResultsThe prevalence of clinical anxiety and clinical depression was 20.4% and 21.8% in Chinese young and middle-aged patients with ONFH, respectively. Binary regression analysis showed that independent risk factors correlated with high incidence of clinical anxiety included involved femoral head (OR = 3.168, 95% CI: 1.496 - 6.708) and stages of ONFH (ORIV-V / II = 5.383, 95% CI: 1.664-17.416). Independent risk factors correlated with high incidence of depression included gender (OR = 2.853, 95% CI: 1.467-5.778), comorbid diseases (OR = 4.243, 95% CI: 1.940-9.278) and stages of the disease (OR IV-V/II = 16.963, 95% CI: 4.404-65.331).ConclusionsPatients with bilateral ONFH are inclined to have clinical anxiety, while female patients and patients with comorbid diseases might tend to get clinical depression. Advanced stages of ONFH are independent risk factors for both clinical anxiety and clinical depression.

Invasive electromagnetic field treatment in osteonecrosis of the femoral head: a prospective cohort study.

Introduction :The purpose of this prospective cohort study was to compare the surgical treatment of non-ONFH in adulthood by curettage and bone grafting with treatment by curettage and bone grafting in combination with invasive electromagnetic field treatment using Magnetodyn®. This was assessed by examining whether electromagnetic field treatment has a positive additive effect on the clinical parameters modified Harris Hip Score according to Haddad, Cook and Brinker, Merle d'Aubigné hip score and visual analogue scale, and on the subsequent need for treatment by total hip arthroplasty.Materials and Methodology :The prospective, non-randomised study included 35 patients with unilateral or bilateral osteonecrosis of the femoral head. These were divided into two groups according to the surgical treatment regime and assessed over a 12-month follow-up period. The study group (Group 1) comprised 19 patients (14 men and 5 women) with a total of 22 non-ONFH, who underwent minimally invasive curettage, bone grafting and electromagnetic field treatment (Magnetodyn®) by implantation of a bipolar induction screw. The control group (Group 2) comprised 16 patients (12 men and 4 women) with a total of 18 non-ONFH, who underwent minimally invasive curettage and bone grafting without Magnetodyn® therapy. At the initial pre-operative examination and the 6 and 12-month follow-up, all patients were assessed by clinical examination and radiological monitoring, and by bilateral hip MRI. The clinical evaluation was based on the modified Harris Hip Score according to Haddad, Cook and Brinker, the Merle d`Aubigné hip score and the visual analogue scale (VAS).Results :At the time of follow-up, total hip arthroplasty (THA) had been performed in four patients in Group 1 (18%). In Group 2, four patients (22%) had received a THA (n.s.). Both procedures led to an improvement in the clinical scores (Harris Hip Score, Merle d`Aubigné score and VAS), although no significant difference was observed.Conclusion : The authors conclude that electromagnetic field treatment with Magnetodyn®, using the special signal protocol applied here, as an adjunct to curettage and autologous bone grafting to treat non-ONFH, does not produce better clinical results and does not offer better prophylaxis for the avoidance of total hip arthroplasty over all ARCO stages.

Contralateral osteonecrosis of the femoral head newly developed after increasing the dose of corticosteroids

Nontraumatic osteonecrosis of the femoral head (ONFH) is a debilitating disorder that commonly affects 30to 50-year-old individuals, with corticosteroid use being one of the major causative factors [1]. Although the precise pathogenesis of corticosteroid-induced ONFH remains unclear, both high-dose oral corticosteroid therapy and corticosteroid pulse treatment have been reported to be risk factors, highlighting the importance of the dose of corticosteroids in the development of corticosteroid-induced osteonecrosis [2–7]. Corticosteroid-induced osteonecrosis often affects both femoral heads (50–70 %), and bilateral ONFH is considered to develop concurrently [1, 2]. In contrast, in patients with unilateral ONFH, it is rare that new osteonecrotic lesions subsequently develop in the contralateral femoral head. To our knowledge, there are no reports in the literature regarding the development of new corticosteroidinduced ONFH lesions on the contralateral side. Here we report the case of a patient who developed new ONFH in the contralateral hip after increasing the dose of corticosteroids for a different underlying disease. We clearly indicate that written informed consent for publication was obtained from the patient. Case report

Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: Results from a series of 407 cases

The goal for treatment of osteonecrosis of the femoral head (ONFH) is to relieve pain, preserve the contour of the femoral head, and delay the need for total hip arthroplasty. The free vascularized fibular grafting (FVFG) has been shown to support the subchondral architecture as well as restore local circulation for the necrotic femoral head in treatment of ONFH. This report aimed to present the clinical results of the use of a modified surgical technique of FVFG for treatment of ONFH. Four hundred and seven patients with 578 hips of ONFH were included. The patients' average age was 36.7 years old (ranging 19-55 years old). The disease was staged from II to V based on the Steinberg classification system. By the modified procedure, the vascularized fibular graft was harvested via a lateral incision with fibular osteotomy prior to the exposure of the vascular pedicle, and the removal of necrotic tissue and inset of graft were performed through an anterior approach. The operative time averaged 90 min for unilateral ONFH (ranging 75-110 min) and 190 min for simultaneous treatment of bilateral ONFH (ranging 160-230 min). The average length of follow-up was 5.0 years (ranging 3-10 years). The complications included one infection in one case, temporary loss of sensation of the thigh in eleven cases, and restricted motion of the great toe in nine cases. The Harris hip score of patients improved from 65.0 to 86.9 on average. Radiographic evaluation showed no changes in 331 hips (57.3%), improvement in 195 hips (33.7%) and necrosis progression in 52 hips (9.0%). Twenty-three hips (4.0%) in 20 patients had total hip arthroplasty during the period. These results show that the modified technique of the use of FVFG for treatment of ONFH yields similar postoperative results in comparison to the traditional method.

Unilateral Free Vascularized Fibula Shared for the Treatment of Bilateral Osteonecrosis of the Femoral Head

Between June 2007 and May 2008, 21 patients with bilateral osteonecrosis of the femoral head were surgically treated with implantation of free vascularized fibula obtained from the unilateral donor site. All patients were followed up clinically and radiographically for an average of 3.5 years. The evaluation included operative duration, blood loss, Harris hip score, incidence of complications, and radiological examinations. The time for fibular harvesting was 20min on average. Total operative duration was 100–240min, with an average of 150min. Blood loss averaged 300ml. All transplanted fibula integrated well to the femoral head 3.5years postoperatively with no severe complications observed. The results revealed that unilateral free vascularized fibula is effective for the treatment of bilateral osteonecrosis of the femoral head.

Osteonecrosis of the femoral head and glaucoma caused by topical corticosteroid application

A 37-year-old man was diagnosed with bilateral osteonecrosis of the femoral head (ONFH) and glaucoma. He had no risk factors for either ONFH or glaucoma, except for 24 years' continuous use of topical corticosteroid ointments for treating atopic dermatitis. We determined that the topical steroid had caused both the pathological conditions. It is necessary to recognize that continuous topical corticosteroid therapy may cause the same pathological conditions as those caused by the systemic administration of these agents.

Aseptic necrosis of bilateral femoral heads after pregnancy

Aseptic necrosis, also known as avascular necrosis, ischemic necrosis, and osteonecrosis, is a pathological process caused by impaired blood supply to the affected bone that results in the death of osteocytes and bone marrow cells. Osteoclastic resorption of dead bone induces demineralization, trabecular thinning, and subsequent collapse of the joint surface with fracture of subchondral bone. A clinical diagnosis is made appropriately according to the patient’s symptoms, physical findings, and imaging results compatible with this disease. The precise prevalence of avascular necrosis is unknown; but in the United States, the number of newly diagnosed patients is estimated to be 10,000 to 20,000 per year [1]. Generally, most avascular necrosis of the femoral head is because of alcoholism, steroid use, and trauma. Excessive alcohol intake and usage of prolonged high doses of glucocorticoids are reported to account for more than 90% of cases [1]; other risk factors or conditions associated with avascular necrosis include Gaucher’s disease, pancreatitis, chemotherapy, decompression sickness (Caisson disease), and blood disorders, such as sickle cell disease and polycythemia. However, little is known about whether pregnancy is an etiological factor in femoral head osteonecrosis. We report the cases of two patients with bilateral osteonecrosis of the femoral head after pregnancy after ovulation induction and include a review of the literature. A healthy 27-year-old Taiwanese woman presented with right groin pain for 1 month after giving birth to a 2.8 kg female baby by normal spontaneous delivery (Gravida 1, Para 1, Abortion 0) at 40 weeks’ gestation 6 weeks before this episode. She had been treated with clomiphene citrate to increase the chance of becoming pregnant. The patient had no history of contraceptive drug use, trauma, alcohol drinking, steroid usage, hyperlipidemia, or ovarian hyperstimulation syndrome. Her weight gain during this pregnancy was 15 kg

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.

Treatment of osteonecrosis of the femoral head using autologous cultured osteoblasts: a case report

IntroductionOsteonecrosis of the femoral head is a progressive disease that leads to femoral head collapse and osteoarthritis. Our goal in treating osteonecrosis is to preserve, not to replace, the femoral head.Case presentationWe present the case of a patient with bilateral osteonecrosis of the femoral head treated with autologous cultured osteoblast injection.ConclusionAlthough our experience is limited to one patient, autologous cultured osteoblast transplantation appears to be effective for treating the osteonecrosis of femoral head.

Bilateral Osteonecrosis of the Femoral Head Associated with Pregnancy: Four New Cases and a Review of the Literature

Osteonecrosis is thought to result from the temporary or permanent loss of blood supply to the bones. Without proper nutrition, the bone tissue dies, is resorbed, and collapses. If the process involves the bones in a joint, it often leads to collapse of the joint surface. Four new cases of bilateral osteonecrosis of the femoral head occurring during pregnancy are described, with pathologic examination of core tissue biopsy substantiating the diagnoses. Operative and nonoperative management included anti-inflammatory medication, pulsating electromagnetic fields, core decompression, and total hip replacement. A review of the literature is undertaken to document the reported cases of osteonecrosis of the femoral head associated with pregnancy. Idiopathic osteoporosis of the femoral head is a condition that mimics osteonecrosis of the femoral head and can be a challenge in diagnosis during the latter stages of pregnancy. Bilateral osteonecrosis of the femoral head during pregnancy is rare. Patients may have other predisposing factors leading to femoral head necrosis. Transient osteoporosis of the femoral head during pregnancy can present with a clinical picture similar to osteonecrosis. Avascular necrosis of the femoral head should be considered in the differential diagnosis of pain about the hip developing during pregnancy or in the immediate postpartum period.

Effects of alendronate medication on the fate of the necrotic femoral head of rats with or without core decompression

After producing bilateral osteonecrosis of the femoral head, rats were medicated alendronate according to one of 6 schedules. In group 1 injection was administered one week prior to the operation of devascularization and thereafter was continued for another 42 days. In group 2, medication started on the day of the operation. The control group 3 was similarly handled except that they were given injections of physiological saline. Group 4 animals were subjected to drilling of the right femoral head and treated with alendronate a week before the operation and 42 days thereafter, while in group 5 medication begun on the day of the operation. Control group 6 was similarly handled, but received physiological saline. The furthest advanced changes occurred in groups 3 and 6 (in which an advanced stage of an osteoarthritis–like disorder were observed) followed by groups 4 and 5 (in which alterations were mild to moderate), and finally by groups 1 and 2 (in which there were but mild changes). In addition, all changes were less pronounced in the animals which had been treated with alendronate for one week prior to the operation than in those given the first dose from the operative day. These findings demonstrate that bisphosphonate medication preserves the shape of rats’ femoral heads in the early post–necrotic phase to a greater degree than in the Authors’ earlier, diverse attempts to arrest the disastrous progression of the post–necrotic remodeling towards hip osteoarthritis. The presented findings warrant the preclinical trial of bisphosphonate therapy in patients admitted for the management of osteonecrosis of the femoral head.

Concurrent Bilateral Femoral Neck Stress Fractures and Osteonecrosis of the Hip: A Case Report

Although bilateral osteonecrosis of the femoral head and bilateral stress fracture of the femoral neck are well-documented conditions, the occurrence of both conditions in the same patient has not been reported, to our knowledge. We present the case of a patient with both entities who was managed with internal fixation of both hips, which provided stabilization of the stress fractures as well as treatment of the osteonecrosis with core decompression. Two years after treatment, the stress fractures had healed and there was no evidence of progression of the osteonecrosis. The patient granted permission for the publication of data concerning the case. Aforty-six-year-old woman presented to us with a six-month history of bilateral groin pain. The right hip was more painful than the left. There was no history of trauma. The medical history included interstitial nephritis, diagnosed on the basis of a renal biopsy performed five years earlier, and osteopenia, diagnosed on the basis of a bone mineral densitometry value that was -1.25 standard deviations below the mean for age and sex-matched controls. The nephritis was treated with a three-month course of prednisone at the time of the initial diagnosis. The serum creatinine level remained elevated at 2.0 to 3.2 mg/dL (176.8 to 282.9 μmol/L), but that level had remained stable since the diagnosis of interstitial nephritis five years earlier. The patient had not received medical treatment for the osteopenia although it was recommended to her at the time that the densitometry was performed. The patient had a history of drug and alcohol abuse more than twenty years previously, but she stated that she had not used drugs or alcohol since that time. There was no history of amenorrhea or an eating disorder. The patient stated that she was an “avid” runner, running >5 mi (>8 km) every morning, prior to …

Bilateral osteonecrosis of the femoral head after pregnancy

Published cases of non-traumatic avascular necrosis of the femoral head associated with pregnancy are rare. We report a case of a 41-year-old woman who suddenly complained of bilateral hip pain 3 weeks after delivery by Caesarean section. For a problem of sterility, she had been treated with human menopausal gonadotropin and human chorionic gonadotropin (hMG-hCG). Initial radiographs of both hip joints were considered regular. After 4 years' evolution, radiographs of the hip joint showed collapse of both femoral heads. Bilaterally, osteonecrosis of the femoral heads was confirmed by MRI. MRI revealed a band pattern of low signal intensity for both hips on T1- and T2-weighted images. She had no history of steroid therapy or alcohol abuse. Osteonecrosis was related to pretentaine. A bilateral total hip arthroplasty was performed. The literature about avascular necrosis of the femoral head associated with pregnancy in previous cases is reviewed.

Osteonecrosis in Protease Inhibitor-Treated Patients

The introduction of protease inhibitors has proven a watershed in human immunodeficiency virus infection therapy and has initiated an era of highly active antiretroviral therapy. However, the numerous data on the effectiveness of these therapeutic regimens have been cited with an ever-growing number of communications concerning adverse reactions. In particular, the widescale use of protease inhibitors has underlined a series of events not evidenced in the controlled clinical studies that permitted the registration of these drugs. We are conducting a cohort multicenter study to evaluate the incidence of adverse events during treatment with protease inhibitors. To date, 4 cases of bilateral osteonecrosis of the femoral head have been reported out of 1073 person-years. While the pathogenesis of this event is unclear, it may be a long-term complication of protease inhibitor treatment.

Osteonecrosis of the femoral head in haemophiliacs: not all joint disease is haemophilic arthropathy.

Osteonecrosis (ON) is rare while arthropathy is common in persons with haemophilia. A recent case of bilateral ON of the femoral head prompted us to review our experience with hip arthroplasty. We identified nine patients with presumed end-stage haemophilic arthropathy. Four of the nine individuals had radiographic findings suggestive of ON, but without unequivocal microscopic evidence of ON. It is important to recognize ON at an early stage because there are surgical interventions which may prolong the life of the joint and improve quality of life. We suggest that ON should be included in the differential diagnosis of hip pathology in persons with haemophilia presenting with hip pain or dysfunction.

Case report 662

We present a case of suppurative arthritis occurring in a patient with bilateral osteonecrosis of the femoral head. Predisposing factors were chronic alcoholism (osteonecrosis) and septicemia due to intravenous drug abuse (suppurative arthritis). Although the association of suppurative arthritis and osteonecrosis is rarely reported in the literature, the prevalence of osteonecrosis and of various factors predisposing to the development of suppurative arthritis should remind us of the possibility that a patient with osteonecrosis who develops sudden worsening of joint pain or fever may have developed suppurative arthritis of the affected joint, particularly when there is evidence of bone destruction.

Incidence and Pathogenesis of Alcohol-Induced Osteonecrosis of the Femoral Head

Anteroposterior pelvic roentgenograms of 790 patients admitted for treatment of alcoholism were examined for evidence of osteonecrosis of the femoral head. Laboratory data on these patients, obtained shortly after admission, demonstrated that average serum cholesterol levels were within normal limits and average serum triglyceride levels were moderately elevated only in those individuals classified as having a severe addition to alcohol. Non-juxta-articular radiographic abnormalities of the femoral head, neck and shaft were common but no changes were observed which were considered to be early indications of structural insufficiency. Two patients had advanced idiopathic bilateral osteonecrosis of the femoral head. One of these patients had undergone one total hip replacement prior to his current admission. This study indicates that there is a very low incidence of osteonecrosis among alcoholics (less than 0.3%). However, alcoholism may lead to osteonecrosis in certain predisposed individuals. A combination of several factors such as systemic fat embolism, elevated circulating levels of inflammatory fatty acids or prostaglandins, and osteoporosis and Charcot-like effects, which are also associated with corticosteroid-induced osteonecrosis, seem to be involved and may contribute, as well, to other instances of femoral head osteonecrosis.