Bilateral Osteonecrosis Research Articles

Radiation-Induced Bilateral Hip Osteonecrosis and Acetabular Fractures

The case report talks about the surgical treatment of bilateral hip osteonecrosis after radiotherapy. The literature is poor on the subject even if a cause-effect correlation is described between radiotherapy and bone necrosis. This clinical case underlines the correlation between pelvic irradiation and radiation-induced fractures due to bone weakening. The evaluation about choice and survival of the implant used is interesting for future comparisons and surgical approach.

Mesenchymal Stem Cell Therapy for Bone Repair of Human Hip Osteonecrosis with Bilateral Match-Control Evaluation: Impact of Tissue Source, Cell Count, Disease Stage, and Volume Size on 908 Hips.

We investigated the impact of mesenchymal stem cell (MSC) therapy on treating bilateral human hip osteonecrosis, analyzing 908 cases. This study assesses factors such as tissue source and cell count, comparing core decompression with various cell therapies. This research emphasizes bone repair according to pre-treatment conditions and the specificities of cell therapy in osteonecrosis repair, indicating a potential for improved bone repair strategies in hips without femoral head collapse. This study utilized a single-center retrospective analysis to investigate the efficacy of cellular approaches in the bone repair of osteonecrosis. It examined the impact on bone repair of tissue source (autologous bone marrow concentrate, allogeneic expanded, autologous expanded), cell quantity (from none in core decompression alone to millions in cell therapy), and osteonecrosis stage and volume. Excluding hips with femoral head collapse, it focused on patients who had bilateral hip osteonecrosis, both pre-operative and post-operative MRIs, and a follow-up of over five years. The analysis divided these patients into seven groups based on match control treatment variations in bilateral hip osteonecrosis, primarily investigating the outcomes between core decompression, washing effect, and different tissue sources of MSCs. Younger patients (<30 years) demonstrated significantly better repair volumes, particularly in stage II lesions, than older counterparts. Additionally, bone repair volume increased with the number of implanted MSCs up to 1,000,000, beyond which no additional benefits were observed. No significant difference was observed in repair outcomes between different sources of MSCs (BMAC, allogenic, or expanded cells). The study also highlighted that a 'washing effect' was beneficial, particularly for larger-volume osteonecrosis when combined with core decompression. Partial bone repair was the more frequent event observed, while total bone repair of osteonecrosis was rare. The volume and stage of osteonecrosis, alongside the number of injected cells, significantly affected treatment outcomes. In summary, this study provides comprehensive insights into the effectiveness and variables influencing the use of mesenchymal stem cells in treating human hip osteonecrosis. It emphasizes the potential of cell therapy while acknowledging the complexity and variability of results based on factors such as age, cell count, and disease stage.

Corticosteroid-associated osteonecrosis of the femoral head in an 87-year-old patient following treatment for COVID-19-associated pneumonia: A case report.

Coronavirus disease 2019 is known to cause severe acute respiratory syndrome, and serious cases need to be treated with corticosteroids. Herein, we report an 87-year-old woman who developed bilateral osteonecrosis of the femoral head after corticosteroid treatment for coronavirus disease 2019-related pneumonia. Sixteen months after treatment, she developed right hip pain without any evidence of trauma. A diagnosis of bilateral osteonecrosis of the femoral head was made based on sclerotic bands on plain radiographs and low-signal bands on T1-weighted magnetic resonance images. The patient underwent right total hip arthroplasty 4months after symptom onset. Histological examination of the resected femoral head revealed pathological evidence of osteonecrosis. The postoperative course was good, and the patient can now walk unassisted. To the best of our knowledge, this is the first report of histologically proven osteonecrosis after corticosteroid therapy for coronavirus disease 2019-related disease.

Bilateral osteonecrosis of the external auditory canal in a patient on bisphosphonates

Bilateral osteonecrosis of the external auditory canal in a patient on bisphosphonates

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

Bilateral extensive steroid-associated osteonecrosis (SAON) of femur, tibia and patella: Successful early management with combined antiresorptive and anabolic bone agents

Bilateral extensive steroid-associated osteonecrosis (SAON) of femur, tibia and patella: Successful early management with combined antiresorptive and anabolic bone agents

Plasma Therapy for Medication-Related Osteonecrosis of the Jaws- a Case Report

Medication-related osteonecrosis of the jaw (MRONJ) is a side effect of anti-bone resorption medications. Nowadays antiresorptive medications like bisphosphonate and monoclonal antibodies like denosumab that have been prescribed for bone disorders and metastatic cancer are becoming increasingly common. Although these medications are quite efficient at reducing bone resorption, they can develop osteomyelitis and jaw necrosis as a side effect. A 65-year-old woman was referred to the Oral Medicine Department of Semnan University of Medical Sciences with diffuse bilateral mandibular osteonecrosis, with a history of osteopetrosis and under-treatment of bisphosphonate. This complication started after tooth extraction and without any healing 5 years ago. After 3 sessions of plasma therapy, obvious improvement was seen. A proper medical history and a routine oral examination before treating with any invasive dental treatment are necessary to avoid any medication-related osteonecrosis of the jaw or mucosal abnormalities.

Imaging of Pancreatitis, Panniculitis, and Polyarthritis Syndrome

HomeRadiologyVol. 307, No. 4 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyImaging of Pancreatitis, Panniculitis, and Polyarthritis SyndromeLakhdeep Singh Brar , Yatin ChadhaLakhdeep Singh Brar , Yatin ChadhaAuthor AffiliationsFrom the Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, Canada N6A 3K7 (L.S.B.); and Department of Medical Imaging, North York General Hospital, Toronto, Canada (Y.C.).Address correspondence to L.S.B. (email: [email protected]).Lakhdeep Singh Brar Yatin ChadhaPublished Online:May 2 2023https://doi.org/10.1148/radiol.222426MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 64-year-old man initially presented with pancreatitis that required hospitalization. Several months later, he developed knee pain and a fluctuant soft tissue mass at the lateral aspect of the left knee. Rheumatologic and metabolic workups (serum calcium and phosphate, and parathyroid hormone) were negative. Radiography performed 10 months after the initial onset of pancreatitis (Figure, A) showed bilateral symmetric osteopenia involving the knees with a permeative appearance of the bones. Subsequent bilateral knee MRI scans (Figure, B and C) demonstrated bilateral multifocal osteonecrosis with rim enhancement in the soft tissues of the left knee, supporting panniculitis. Subsequent imaging showed improvement of all imaging findings. The patient was referred to orthopedic oncology at a tertiary care center as a precaution. The diagnosis of pancreatitis, panniculitis, and polyarthritis (PPP) syndrome was made based on the clinical and imaging findings.Images in a 64-year-old man presenting with knee pain 10 months after hospitalization for pancreatitis. (A) Anteroposterior radiograph of both knees shows a permeative appearance of the bones (arrows). (B) Coronal T1-weighted knee MRI scan shows osteonecrosis. (C) Coronal T1-weighted postgadolinium MRI scan shows bilateral multifocal osteonecrosis (arrowheads) and panniculitis (rim enhancing) in the lateral soft tissues of the left knee (arrow).Download as PowerPointOpen in Image Viewer PPP syndrome is rare and occurs in the setting of pancreatitis or an underlying pancreatic mass (1). Patients may report mild or absent abdominal symptoms, making it difficult to diagnose. It has been reported to occur in all age groups, with a mean age ± SD of 51 years ± 16, and has a higher prevalence rate in men than in women (2:1 ratio) (2). While any joint may be involved, it most commonly affects the knees, ankles, and wrists (2). The pathophysiology is thought to result from the release of pancreatic lipase into the circulation, causing lipolysis and inflammation (2). The clinical symptoms and imaging findings can be transient or persist over time (3). Treatment involves addressing the underlying pancreatitis (3).Disclosures of conflicts of interest: L.S.B. No relevant relationships. Y.C. No relevant relationships.

Revisiting prediction of collapse in hip osteonecrosis with artificial intelligence and machine learning: a new approach for quantifying and ranking the contribution and association of factors for collapse.

This study proposes machine learning to analyze the risk factors of the collapse in patients with non-traumatic hip osteonecrosis of the femoral head. We collected data of 900 consecutive patients (634 males) with bilateral (428) or unilateral non-traumatic osteonecrosis diagnosed before collapse (at stage I or stage II). The follow-up was average fiveyears (3 to 8years). A total of 50 variables related to the osteonecrosis were included in the study. The osteonecroses were randomly divided into a training set (80%) and a validation set (20%) with a similar percentage of hips with collapse in the two groups. Machine learning (ML) algorithms were trained with the selected variables. Performance was evaluated and the different factors (variables) for collapse were ranked with Shapley values. The primary outcome was prediction of occurrence of collapse from automated inventory systems. In this series of patients, the accuracy with machine learning for predicting collapse within threeyears follow-up was 81.2%. Accuracies for predicting collapse within six to12-24months were 54.2%, 67.3%, and 71.2%, respectively, demonstrating that the accuracy is lower for a prevision in the short term than for the mid-term. Despite none of the risk-factors alone achieving statistical significance for prediction, the system allowed ranking the different variables for risk of collapse. The highest risk factors for collapse were sickle cell disease, liver, and cardiac transplantation treated with corticosteroids, osteonecrosis volume > 50% of the femoral head. Cancer (such as leukemia), alcohol abuse, lupus erythematosus, Crohn's disease, pemphigus vulgaris treated with corticosteroids, and osteonecrosis volume between 40 and 50% were medium risk factors for collapse. Familial cluster of collapse, HIV infection, chronic renal failure, nephrotic syndrome, and renal transplantation, when treated with corticosteroids, stage II, osteonecrosis volume between 30 and 40%, chemotherapy, hip pain with VAS > 6, and collapse progression on the contralateral side, were also significant but lowest risk factors. A heat map is proposed to illustrate the ranking of the combinations of the different variables. The highest risk of collapse is obtained with association of various risks factors. This study, for the first time, demonstrated prediction of collapse and ranking of factors for collapse with a machine learning system. This study also shows that collapse is due to a multifactorial risk factors.

Bilateral Hindfoot Osteonecrosis Associated with Treatment for Cutaneous T-Cell Lymphoma

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: There are reports of bilateral atraumatic osteonecrosis of the talus associated with some chemotherapy agenst for cutaneous T-cell lymphomas (CTCL), and systemic glucocorticoid treatment is by far the most common. We report the case of a 63-year old woman with CTCL previously treated with a high-affinity folate analog, pralatrexate, and multiple short- courses of prednisone dose packs who developed bilateral ankle and hindfoot stress fractures which progressed to hindfoot necrosis involving the talus and calcaneus. Methods: Chart Review Results: MRI was used for the diagnosis of stress fractures and osteonecrosis. The right foot was most symptomatic at presentation and was treated with a 6-month period of protected weight bering in a CAM boot. Follow up imaging demonstrated complete collapse of the talar dome. The patient underwent tibiotalarcalcaneal fusion which was complicated by wound healing issues requiring a skin graft. During this time, left sided symptoms worsened, and MRI confirmed insufficiency fractures with adjacent areas of edema and necrosis about the calcaneus, talus, and lateral malleolus. Considering her recent wound healing difficulties, the left foot was definitively treated in a CAM walker boot with some improvement in symptoms. Conclusion: Insufficiency fractures of the hindfoot are known to progress to osteonecrosis and are typically associated with long- term or high dose systemic steroid administration. Cases presenting after short-courses of oral steroids are uncommon; those associated with methotrexate (a lower affinity folate analog) are rare, and cases associated with pralatrexate or CTCL outside osteonecrosis of the jaw were not found during literature review. Despite cessation of chemotherapy and CTCL remission and early institution of protected weight, this patient rapidly progressed to bilateral hindfoot collapse. Providers and patients should be aware of the associated risks and potential for less favorable outcomes.

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.

Osteonecrosis of the femoral head after COVID-19: a case series

It is known that COVID-19 has an adverse effect on various organs and systems of the human body. In the available literature, there are isolated reports regarding the development of osteonecrosis after suffering COVID-19. These papers discuss the role of commonly used corticosteroids in the treatment of COVID-19 in the development of osteonecrosis. Our article presents clinical observations of four patients with bilateral osteonecrosis of the femoral heads after treatment with COVID-19. The doses of prednisolone in three patients were 4500 mg, 735 mg and 525 mg. One patient did not receive corticosteroids. Our data showed that osteonecrosis in COVID-19 survivors developed at a shorter time compared to osteonecrosis in patients without coronavirus infection. Two out of four patients had a positive family history (myocardial infarction, hypertension, thrombosis). It is possible that hereditary vascular factors played some role in the genesis of osteonecrosis of the femoral head. Further evidence is needed to understand the development of osteonecrosis after COVID-19. Probably, the development of the disease is synergistically affected by many factors, including steroid and ischemic.

Avascular Necrosis of the Femoral Head After COVID-19: A Case Series

The coronavirus disease-2019 (COVID-19) has adverse effects on various organs and systems. There are isolated reports concerning the development of osteonecrosis after COVID-19. These papers discuss the role of corticosteroids widely used in the treatment of COVID-19 in the development of osteonecrosis. This article presents clinical observations of four patients with bilateral osteonecrosis of the femoral heads after treatment with COVID-19. Prednisone doses in three patients were 4000 mg, 746 mg, and 533 mg. Corticosteroids were not used in one patient. Data showed that osteonecrosis in patients who underwent coronavirus developed in a shorter time compared with this pathology in patients without COVID-19. Two of four patients had a burdened family history (such as myocardial infarction, hypertension, and thrombosis). Hereditary vascular factors possibly played some roles in the genesis of the osteonecrosis of the femoral head in these patients. To understand the features of osteonecrosis development after COVID-19, further accumulation of evidence is necessary. Several synergistically influencing factors are important in the development of this disease after COVID-19.

Bilateral stress fracture of the femoral neck in association with simultaneously developing osteonecrosis of the femoral head: a case report

BackgroundFemoral neck stress fractures are rare and often recognized as overuse injuries that occur in young athletes or military personnel. A case following osteonecrosis of the femoral head is quite rare; even more uncommon is its occurrence in the bilateral hips. Magnetic resonance imaging has been established as the preferred tool for diagnosing nondisplaced femoral neck stress fracture due to overuse injury. Magnetic resonance imaging was also useful to detect the initial lesion even in this case, although the etiology was different between overuse injury and insufficiency fracture.Case presentationA 41-year-old Japanese woman diagnosed with bilateral early stage idiopathic osteonecrosis of the femoral head was observed non-weight-bearing as much as possible using a stick. However, her pain and difficulty in walking progressed. Bilateral femoral neck stress fractures were subsequently detected by magnetic resonance imaging. The fracture initially appeared as a spot of bone marrow edema at the medial site of the femoral neck, and then developed into a fracture line. The patient underwent internal fixation of both hips with sliding hip screws to stabilize the stress fractures. In addition, the preparatory reaming served as core decompression of the femoral heads, as well as being treatment for osteonecrosis. Her bone mineral density and 25-hydroxy vitamin D values were low for her age. We administered eldecalcitol and teriparatide acetate. Her symptoms mostly improved, and the fracture lines and necrotic lesions on magnetic resonance imaging reduced at 5 months after the surgery.ConclusionsBilateral femoral neck stress fractures are a very rare condition and are often missed. It is important to listen to the patient’s complaints and perform an appropriate examination. We encountered a case of bilateral femoral neck stress fracture that occurred in a patient with early stage osteonecrosis of the femoral head, and were able to observe progression of stress fracture since before fracture occurred. This is considered to be the first report to capture imaging changes before and after the onset.

Late Radiation-Related Toxicities in Patients Treated for Early-Stage Cervical Carcinoma by Surgery and Adjuvant Radiotherapy: A Retrospective Imaging Study.

Surgical treatment is preferred therapy of early-stage cervical carcinoma. In the risk of cancer recurrence surgery is often followed by adjuvant radiotherapy. In our retrospective study we aimed at identifying late (≥6 months) and very late (≥5 years) radiation adverse effects on imaging scans as CT, PET/CT and MRI in patients who underwent successful treatment for cervical carcinoma by radical surgery combined with radiotherapy ± chemotherapy. We correlated imaging results with clinical manifestations. We selected young and middle-aged patients with long life expectancy, as late radiation-related toxicities may significantly affect their quality of life. Patients were selected from those who were primary diagnosed and treated between the years 1987–2011 and regularly visited our Oncology department in years 2011–2012. Following inclusion criteria were applied: age ≤55 years at diagnosis, clinical follow-up ≥5 years and at least one tomography scan ≥3 years after finished treatment. One hundred and three subjects were reviewed: 73 patients met all inclusion criteria, while 30 patients fulfilled the inclusion criteria except for available tomography scan ≥3 years after therapy. The mean imaging follow-up was 11.2 ± 7.6 years and the mean clinical follow-up was 15.0 ± 6.9 years. In 20 (27%) subjects 27 cases grade I radiation-related toxicities were found; 9 (33%) of those 27 cases were clinically silent. In 14 (19%) females only grade I toxicities were observed. Grade III-IV toxicities were found in 5 (6.8%) subjects. No grade V toxicities were observed. We concluded that severe late side effects caused by radiotherapy were exceedingly rare in females successfully treated for early-stage cervical carcinoma, only 1 bilateral osteonecrosis, 2 cases of ileus, and 2 potentially radiation-induced tumors were found. The majority of radiation-related comorbidities found on imaging scans were clinically silent.

Spontaneous bilateral femoral neck subcapital fractures in bilateral osteonecrosis of the femoral head: A case report and review of the literature

Femoral neck fracture rarely occurs during the course of osteonecrosis of the femoral head (ONFH). We report a case of spontaneous bilateral femoral neck subcapital fractures in the presence of bilateral ONFH. A 30-year-old man developed bilateral hip pain while working. Plain radiographs revealed bilateral displaced subcapital fractures of the femoral neck. Magnetic resonance imaging (MRI) scans demonstrated a typical finding of bilateral ONFH. The fractures were treated with bilateral total hip arthroplasty. He had recovered satisfactorily and could return to work without any problem. ONFH rarely causes bilateral femoral neck fractures. We performed routine laboratory blood examinations and biochemical and endocrine tests, which excluded the possibility of any underlying metabolic disorders. We also performed MRI to evaluate the severity of ONFH. Fractures occurred in the subcapital area between the interface of necrotic and regenerative bone. ONFH may suddenly deteriorate to become a femoral neck fracture without head collapse or any recognizable trauma event. Although rare, bilateral hip involvement is possible. Care should be directed to the proper diagnosis and appropriate treatment of such fractures.

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.

A case of bilateral hip and knee osteonecrosis in a patient with ankylosing spondylitis who used steroids due to immune thrombocytopenic purpura

We aim to present a case of bilateral hip and knee osteonecrosis due to steroid use in an ankylosing spondylitis (AS) patient who developed immune thrombocytopenic purpura (ITP) after the use of nonsteroidal anti-inflammatory drugs (NSAID). A 60-year-old male patient was diagnosed with AS with bilateral sacroiliitis and inflammatory low back pain on sacroiliac radiography 10 years ago. He was followed up with NSAIDs. Intravenous steroid treatment was started in the hematology clinic to the patient who had developed ITP due to NSAID usage. The patient presented to our clinic with bilateral hip pain that developed after steroid therapy. He had limited hip joint movement and bilateral destructive hip joints in pelvic radiography. Bilateral total hip arthroplasty (THA) was performed by the Orthopedics and Traumatology Department at 1-year intervals because of osteonecrosis associated with steroid use. When he presented to our clinic 3 years later with bilateral knee pain, we detected osteonecrosis in the distal segments of bilateral femurs and proximal tibial diaphysis on knee MRI. We implemented a rehabilitation program with the conservative treatment recommendation of orthopedics. Comorbidities or drug side effects should be examined more carefully while treating peripheral joint involvement in patients with AS.

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.