Cases Of Avascular Necrosis Research Articles

Evaluation of Femoral Head Avascular Necrosis With Virtual Noncalcium Dual-Energy Computed Tomography.

Our aim was to investigate the effectiveness of the dual-energy computed tomography (DECT) virtual noncalcium (VNCa) technique in avascular necrosis (AVN) for detecting bone marrow edema (BME) and staging. This prospective study included adult patients diagnosed with unilateral or bilateral femoral head AVN between January 2023 and December 2023, who had magnetic resonance imaging (MRI) and DECT. Two participants were excluded from the study due to undergoing surgical procedures during the period between the scans. Two reviewers, blinded to MRI images and clinical data, visually examined color-coded VNCa pictures to assess BME using a binary classification (0 = normal bone marrow, 1 = BME). Same 2 reviewers also used color-coded and nonmapped images to stage AVN in accordance to the "Association for Research on Osseous Circulation" (ARCO) staging system. Interobserver agreements for the visual evaluation and staging were calculated with κ coefficient. Following a visual assessment of BME and the staging of AVN, same 2 reviewers conducted CT density measurements on regions of BME regions utilizing DECT noncalcium images. An independent third investigator (reference standard) utilized MRI, x-ray, and clinical data to confirm the definitive diagnosis and staging of AVN. A P value less than 0.05 was considered statistically significant. Fifty patients (28 men, 22 women, mean age: 44.2 ± 13.1 years, range: 25-75 years) were included in the final analysis. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the VNCa technique in detecting BME were 96.0%, 94.4%, 97.9%, 89.4%, and 95.6%, respectively, for reviewer 1; and 96.0%, 88.9%, 96.0%, 88.9%, and 94.1%, respectively, for reviewer 2. Interobserver agreement was almost perfect ( κ = 0.84). Both reviewer 1 and reviewer 2 accurately classified 92.7% of the AVNs. The density measurements showed a statistically significant difference ( P = 0.001) between the edema regions and the normal marrow regions. No statistically significant difference was observed in the density measurements of edema regions at different stages ( P = 0.13). DECT VNCa technique exhibits excellent performance in detecting BME in hip AVN cases, as well as accurately determining the stage of AVN.

Advances in Management of Pediatric Capitellum Fractures: A Retrospective study

Background: Capitellum fractures are rare in the pediatric population, with most documented cases occurring in individuals over 12 years old. These fractures present unique challenges in diagnosis and treatment due to the rarity and complexity of pediatric bone healing. The limited literature on this subject often emphasizes adult treatment protocols, leaving gaps in understanding pediatric cases. This study investigates the outcomes of six children, aged 12 to 16, with displaced capitellum fractures treated with open reduction and internal fixation (ORIF). Methods: Between 2000 and 2020, six pediatric patients with displaced capitellum fractures were treated at AL-Hussain Teaching Hospital. All fractures were classified as type 1 Hahn-Steinthal fractures and were managed using ORIF with screw fixation. Postoperatively, patients were immobilized for three weeks and followed up clinically and radiologically for 20 months to 4 years to assess pain, range of motion, and any complications. Results: All patients achieved solid fracture union with no cases of avascular necrosis, heterotopic ossification, or infection. Following cast removal, patients initially experienced stiffness but ultimately regained full elbow function, with only two patients experiencing minor flexion loss. There were no radiological signs of degenerative changes or deformities. Conclusion: ORIF using screw fixation is effective in managing displaced capitellum fractures in pediatric patients, resulting in solid union and good functional outcomes. Early intervention and careful postoperative management are crucial in minimizing complications. However, the rarity of these injuries underscores the need for further research to establish standardized treatment protocols.

Treatment of AVN-Induced Proximal Pole Scaphoid Nonunion Using a Fifth and Fourth Extensor Compartmental Artery as a Vascularized Pedicle Bone Graft: A Retrospective Case Series.

BACKGROUND Scaphoid nonunion (SN) is a challenging condition in wrist pathology, often resulting in severe consequences if left untreated. Surgical intervention, particularly using vascularized bone grafts (VBGs), is a promising but uncertain approach. The 4+5 extensor compartment artery (ECA) pedicled graft, less commonly used for SN, has potential benefits due to its vascular supply and accessibility to the scaphoid. This study aimed to evaluate the effectiveness of the 4+5 ECA pedicled graft combined with headless compression screw fixation in treating avascular necrosis (AVN)-induced proximal pole SN. Radiological results, functional outcomes, and complications related to this method were assessed. MATERIAL AND METHODS This was a retrospective analysis of 19 proximal pole SN cases with AVN treated using the 4+5 ECA-VBG technique from 2016 to 2022. Patients underwent preoperative evaluation and postoperative follow-up for at least 1 year. Data on surgery, demographics, radiological assessments, and functional outcomes were recorded and analyzed statistically. RESULTS All patients achieved radiographic union within 8.5 weeks postoperatively, with revascularization of proximal pole necrosis. Significant improvements in functional outcomes were observed, including pain reduction, increased wrist range of motion, improved grip and pinch strength, and enhanced wrist scores. No major complications were reported. CONCLUSIONS The 4+5 ECA-VBG technique, with headless compression screw fixation, showed high success rates in treating AVN-induced proximal pole SN. This method offers comprehensive restoration of wrist function and minimal complications, making it a viable option for SN management, especially in AVN cases. Further research is needed to confirm these results and establish standardized protocols for SN treatment.

Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

Introduction/Purpose: Avascular necrosis (AVN) is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is considered to be a strong predictor of preserved talus vascularity. The study sought to assess the accuracy of the Hawkins sign in a large, contemporary cohort and assess factors associated with inaccuracy. Methods: A retrospective review of all talar neck fractures from a single level I trauma center from 2008 to 2016 was performed. The presence of Hawkins sign and AVN were determined based on ankle radiographs 8 weeks after injury and at final follow-up, respectively. Patients with less than 6 months follow-up were excluded. Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (C.I.) and associations were examined with Fisher’s exact testing. Results: In total, 137 talar neck fractures were identified with 105 having adequate follow-up. Hawkins sign was observed in 21 tali, 3 (14%) of which later developed AVN (95% C.I., 3 – 36%). In the remaining 84 tali without Hawkins sign, 32 (38%) developed AVN (95% C.I., 28 – 49%). Of the 3 tali that developed AVN following observation of Hawkins sign, all patients were smokers. There were no cases of AVN in non-smokers with Hawkins sign (P=0.21), and smoking was not associated with AVN in patients without Hawkins sign (41% vs 36%, P=0.82). Conclusion: Hawkins sign may not be a reliable predictor of preserved talus vascularity in all patients. We identified three patients with positive Hawkins signs who developed AVN, all of whom were smokers. Factors impairing microvascular blood supply to the talus may lead to AVN even in the presence of preserved macrovascular blood flow and an observed Hawkins sign. Close monitoring of select patients with Hawkins sign should be considered and further research is needed to understand the factors limiting Hawkins sign accuracy. Prognostic accuracy of the Hawkins sign in predicting talar AVN

Acetabular "Fleck" Sign: Outcomes of Surgical Repair.

Traumatic, posterior hip dislocations in the pediatric population are typically managed by closed reduction to achieve a concentric hip joint. The presence of an acetabular "fleck" sign, despite concentric reduction, has been shown to signify significant hip pathology. The purpose of this study was to evaluate the outcomes of open labral repair through a surgical hip dislocation (SHD) in a consecutive series of patients with an acetabular "fleck" sign associated with a traumatic hip dislocation/subluxation. A retrospective review of patients between 2008 and 2022 who presented to a single, level 1 pediatric trauma center with a traumatic posterior hip dislocation/subluxation was performed. Patients were included if they had an acetabular "fleck" sign on advanced imaging and underwent open labral repair through SHD. Medical records were reviewed for sex, age, laterality, mechanism of injury (MOI), and associated orthopaedic injuries. The modified Harris hip score (mHHS) was utilized as the primary clinical outcomes measure. Patients were assessed for the presence of heterotopic ossification (HO) and complications, including implant issues, infection, avascular necrosis (AVN), and post-traumatic dysplasia. Twenty-nine patients (23 male, average age: 13.0±2.7 y; range: 5.2 to 17.3) were identified. Eighteen injuries were sports related, 9 caused by motor vehicle accidents, and 1 pedestrian struck. All patients were found to have an acetabular "fleck" sign on CT (26 patients) or MRI (5 patients). Associated injuries included: femoral head fracture (n=6), pelvic ring injury (n=3), ipsilateral femur fracture (n=2), and ipsilateral PCL avulsion (n=1). At the latest follow-up (2.2±1.4y), all patients had returned to preinjury activity/sport. Three patients developed asymptomatic, grade 1 HO in the greater trochanter region. There was no incidence of AVN. One patient developed post-traumatic acetabular dysplasia due to early triradiate closure. mHHS scores showed excellent outcomes (n=21, 94.9±7.4, range: 81 to 100.1). The acetabular "fleck" sign indicates a consistent pattern of osteochondral avulsion of the posterior/superior labrum. Restoring native hip anatomy and stability is likely to improve outcomes. SHD with open labral repair in these patients produces excellent clinical outcomes, with no reported cases of AVN. Level IV-therapeutic.

Natural course of talar avascular necrosis during short-term follow-up and factors associated with Disease progression

BackgroundThis retrospective cohort study aimed to investigate the natural history of talar avascular necrosis (AVN) during short-term outpatient follow-up and to identify the risk factors for progression to collapse and arthritic changes.MethodsThirty-four cases of talar AVN from 34 patients (15 males, 19 females) were included. The mean age of the patients was 48.9 years (SD 16.0 years) and the mean follow-up period was 39.5 months (SD 42.0 months). The patients were divided into two groups i.e., progression and non-progression groups. The progression group consisted of those who showed aggravation of the Ficat stage during the follow-up period or advanced arthritis of the ankle joint (Ficat stage 4) at presentation. Demographic data and information regarding BMI, medical comorbidities, trauma history, bilaterality, and location of the lesion (shoulder vs. non-shoulder lesions) were collected. Following the univariate analysis, a binary logistic regression analysis was performed.ResultsThe location of the talar AVN was the only significant factor (p = 0.047) associated with disease progression. A total of 14.3% (2 of 14) of the central (non-shoulder) talar AVN lesions showed progression, while 50% (10 of 20) of shoulder lesions aggravated during follow-up. Age, sex, bilaterality, medical comorbidities, and trauma history were not associated with progressive talar collapse or subsequent arthritic changes in talar AVN.ConclusionsConservative treatment should be considered for a central lesion of the talar AVN because it tends to remain stable without progression. A more comprehensive study with a larger study population is required to establish the surgical indications for talar AVN.Level of evidencePrognostic level III.

Ayurvedic Management of Avascular Necrosis of head of Femur: A Case Report

Avascular Necrosis (AVN) is a pathological condition characterised by a reduction in the blood supply to the subchondral bone, leading to the degenerative condition of the bone, marked by the death of cellular components of the bone. It is also known as osteonecrosis. The epiphysis of long bones at weight-bearing joints is typically affected. All of these conditions have a poor prognosis. In Ayurveda, it corresponds to Asthivahastrotodushtivikara (musculoskeletal disorder) as there is kshaya (necrosis) of asthi (bone) and Majja (bone marrow) dhatu (major structural components of the body). In modern medicine, AVN is managed by the use of corticosteroids and many surgical procedures such as drilling, insertion of prosthetics, or bone grafts. Therefore, Ayurveda provides a conservative line of treatment based on the principle of Asthi-majjagatkashaya (decalcification of bone) caused by abhighatajanyavataprakopa (trauma). A case of AVN with the right femoral head was treated with shaman (oral medications), Sodhana (bio-purification), and bruhmana (rejuvenation) procedures. The therapy provided significant improvements in pain and range of movement of the hip joint, based on the patient’s signs and symptoms before and after treatment. Conservative treatment can give outstanding results, improve the quality of life, halt disease progression, and help manage AVN by tissue regeneration without harmful effects.

Intramedullary Plating of Complex Proximal Humerus Fractures: A Case Series.

To assess fracture union rates using novel intramedullary plate technique. Post-operative humeral neck-shaft angles, patient range of motion and complication profile were secondary outcomes of interest. Single surgeon, retrospective case series of surgical technique at major trauma centre in Scotland. A 2.0mm mini-fragment plate was secured to the humeral head to act as an intramedullary strut during fixation in complex proximal humerus fractures. Fracture union and neck-shaft angle were assessed radiologically, whilst range of motion and complication profiles were assessed clinically. Twelve patients were followed up for an average of 10 months post-operatively. All achieved bony union with a mean neck-shaft angle of 128°. Mean range of motion values were 100° forward elevation, 83° abduction, 60° internal rotation and 37° external rotation. Four patients required further surgical intervention- two for hardware prominence, one for adhesive capsulitis and one for subsequent rotator cuff failure. There were no cases of avascular necrosis or infection. This novel technique addresses the established biomechanical propensity of proximal humerus fractures to fail in varus collapse and screw cut-out. This method provides an alternative to arthroplasty in the most severe proximal humerus fractures and is readily adopted via standard orthopaedic kit.

Patient-based outcomes of slipped capital femoral epiphysis after treatment with in-situ percutaneous fixation

Abstract Introduction: Percutaneous in situ fixation with a single screw is regarded as safe and remains the gold standard of treatment for slipped capital femoral epiphysis (SCFE). However, reliance is based on subsequent remodeling of the femoral neck. Healing in a non-anatomic position may predispose the patient to femoral-acetabular impingement (FAI) and degenerative arthritis of the hip. Consequently, some surgeons advocate for surgical hip dislocation and reduction of severe SCFE. This study aimed to assess patient-based outcomes after in situ pinning. Methods: Twenty-six patients (36 hips) with SCFE treated at our institution between 2011 and 2016 were included in this retrospective study. Patients with less than two years’ follow-up and those without prior radiographs were excluded. Hips were radiologically classified into three groups: mild, moderate, and severe SCFE. Outcome measures included a modified Harris Hip Score and Visual Analogue Pain Score. Results: There were no cases of avascular necrosis in both mild and moderate slips treated with in situ pinning. Only one avascular necrosis (AVN) was reported out of eleven severe slips (9.1%). This is significantly lower than previous studies that evaluated in situ pinning in severe slips. In addition, one FAI case developed in eleven severe slips (9.1%). Conclusion: Our results suggest that in situ percutaneous pinning is safe and has a low complication rate. High patient satisfaction in pain and function suggests that remodeling is effective regardless of the severity of the slip.

Avascular Necrosis - A Conceptual Interpretation in Ayurveda

Avascular Necrosis is a major health problem which results in the complete collapse of a Bone which may end up in permanent disabilities in the patient. Ayurveda with its vast concept of effective analysis and treatment aspects can be much fruitful in Avascular Necrosis cases without hampering other systems of the body. Here in this article an attempt is made to understand Avascular Necrosis by the concepts of Vatarakta in understanding its pathogenesis and its Treatment.

Postoperative Valgus Deformity and Progression of Ostheoarthritis in Non-Displaced Femoral Neck Fractures.

Nondisplaced femoral neck fractures have traditionally been treated with in situ fixation. However, poor surgical and clinical outcomes have been reported for fractures with valgus deformity >15°, and the reduction of valgus impaction has recently been emphasized. In addition, early degenerative osteoarthritis can be caused by cam-type femoroacetabular impingement after healing of femoral neck fractures. This study was designed with the objective of confirming the difference in progression of radiographic osteoarthritis according to the severity of the valgus deformity. Patients who underwent internal fixation using multiple cannulateld screws for management of nondisplaced femoral neck fractures were divided into two groups: high valgus group (postoperative valgus angle ≥15°) and low valgus group (postoperative valgus angle <15°). Evaluation of demographic data and changes in the joint space width from the immediate postoperative period to the latest follow-up was performed. A significant decrease in joint space width in both hip joints was observed in the high valgus group when compared with the low valgus group, including cases with an initial valgus angle less than 15° and those corrected to less than 15° of valgus by reduction. No complications requiring surgical treatment were observed in either group; however, two cases of avascular necrosis, one in each group, which developed in the low valgus group after reduction of the fracture, were followed for observation. Performing in situ fixation in cases involving a valgus deformity ≥15° in non-displaced femoral neck fractures may cause accelerated narrowing of the hip joint space.

Vitamin D Deficiency and Avascular Necrosis in Patients with Sickle Cell Disease: A Retrospective Cohort Study

Introduction Sickle cell disease (SCD) is an inherited hemoglobinopathy with complex systemic involvement. Avascular necrosis (AVN) is a devastating complication among patients with SCD. Vitamin D deficiency (VDD) is commonly found in SCD patients, but there is limited research on the potential role of VDD as a risk factor for AVN in SCD patients. This study aimed to assess the association between VDD and AVN and determine the patterns, risk factors, diagnosis, and treatment of AVN in SCD patients. Methods We conducted a retrospective cohort study of consecutive SCD patients diagnosed with VDD from January 2020 to December 2022 at Prince Sultan Medical Military City (PSMMC) in Riyadh, Saudi Arabia. Patients meeting the following criteria were included: (1) adults and children with confirmed SCD through hemoglobin electrophoresis and (2) tested for VDD. Patients who underwent bone marrow transplant were excluded. The main outcome measured was the occurrence of AVN. VDD was diagnosed in patients with 25-hydroxyvitamin D levels below 30 nmol/L. Magnetic resonance imaging was used to stage and confirm AVN diagnosis. Associations were assessed using the chi-square test, and logistic regression was performed to control for confounding. Results The study included 711 eligible SCD patients, with 271 (38%) being children. VDD affected 301 out of 711 patients (42.3%). Among these, 212 (70.4%) were adults (&amp;gt;18 years old). VDD was observed in 32.2% of children and 48.1% of adults. Of the total cohort, 127 (17.9%) patients experienced AVN, including 18 children. Among patients with VDD, 89 developed AVN, while VDD affected 212 patients without AVN. The time between VDD diagnosis and AVN presentation ranged from 3 to 12 months. Male patients accounted for 52% of AVN cases. The average age at AVN diagnosis was 30.9 ± 11 years. The most common clinical presentation of AVN was chronic joint pain in over 95% of patients. Other presentations included limping in 3.9% of patients and limited joint movement in one patient. Affected joints included the hip (86%), shoulder (16.5%), knee (4.7%), and sacroiliac joint (0.7%). Bilateral joint involvement was present in 50.4% of AVN patients. The majority of patients (76.4%) were diagnosed with advanced stage AVN (III/IV). Treatment of patients with AVN included joint replacement in 44 (34.6%) patients, while the remaining 83 patients managed with conservative therapy such as pain control and physiotherapy. Patients with a history of VDD were significantly associated with a higher risk of AVN (p &amp;lt; 0.001), as seen in Table 1. Multivariate logistic regression showed SCD patients with VDD had 9.79 times the odds of AVN compared to SCD patients without VDD (OR 9.79; 95% CI: 5.25-18.26). Other statistically significant risk factors for AVN included frequent vaso-occlusive crises (three or more episodes per year), older age, history of acute chest syndrome, and low hemoglobin F levels. Conclusion AVN is a significant cause of morbidity in our SCD cohort, with most patients having advanced AVN disease. VDD is an independent risk factor for AVN in patients with SCD. Well-designed randomized trials are needed to determine the effect of vitamin D supplementation in reducing AVN in children and adults with SCD.

Twenty-Three-Year-Old Collegiate Soccer Athlete With Bilateral Femoral Head Avascular Necrosis: A Case Report

A 23-year-old collegiate club soccer player reported to his athletic trainer right hip flexor pain and no recalled mechanism. Diagnostic imaging revealed bilateral avascular necrosis (AVN) of both femoral heads. Medical intervention included bilateral core decompression surgery. The majority of reported AVN cases are pediatric patients and adults over 50 years old, following trauma (i.e., femoral fracture) being the main risk factor. Although not seen often in athletic populations, athletic trainers should be aware of the possibility of AVN in patients. AVN is a life-altering condition and accurately documenting all patient encounters, and proper interprofessional collaboration is imperative for positive outcomes.

Natural Course of Talar Avascular Necrosis During Short-Term Follow-Up and Factors Associated with Disease Progression

Category: Ankle; Hindfoot Introduction/Purpose: This retrospective cohort study aimed to investigate the natural history of talar avascular necrosis (AVN) during short-term outpatient follow-up and to identify the risk factors for progression to collapse and arthritic changes. Methods: Thirty-four cases of talar AVN from 34 patients (15 males, 19 females) were included. The mean age of the patients was 48.9 years (SD 16.0 years) and the mean follow-up period was 39.5 months (SD 42.0 months). The patients were divided into two groups i.e., progression and non-progression groups. The progression group consisted of those who showed aggravation of the Ficat stage during the follow-up period or advanced arthritis of the ankle joint (Ficat stage 4) at presentation. Demographic data and information regarding medical comorbidities, trauma history, bilaterality, and location of the lesion (shoulder vs. non-shoulder lesions) were collected. Following the univariate analysis, a binary logistic regression analysis was performed. Results: The location of the talar AVN was the only significant factor (p=0.047) associated with disease progression. A total of 14.3% (2 of 14) of the central (non-shoulder) talar AVN lesions showed progression, while 50% (10 of 20) of shoulder lesions aggravated during follow-up. Age, sex, bilaterality, medical comorbidities, and trauma history were not associated with progressive talar collapse or subsequent arthritic changes in talar AVN. Conclusion: Conservative treatment should be considered for a central lesion of the talar AVN because it tends to remain stable without progression. A more comprehensive study with a larger study population is required to establish the surgical indications for talar AVN.

Avascular necrosis of femoral head following COVID-19 infection.

It is crucial to be aware of post-COVID-19 non-pulmonary complications. Avascular necrosis (AVN) is one of these complications. It should be noted that the risk of AVN persists in individuals who have recovered from the COVID-19 infection. The current study aims to report several cases of AVN after being infected with SARS-CoV-2. This is a single-centre retrospective case series conducted over a 2-year period (January 2021-December 2022) involving individuals who developed AVN after being infected with COVID-19. The study included a total of 17 patients. The mean age of patients was 38.65±6.1 years. Twelve of them were male (70.6%) and five were female (29.4%), with a ratio of 3:1. The mean BMI of the patients was 28.3±2.4kg/m2. Eleven (64.7%) patients reported administering steroid injections throughout the infection course. The mean interval between COVID-19 infection and presentation to the clinic was 6.53 months. The majority of patients (82.3%) complained of bilateral hip pain. Limping was observed in 47% of the cases. MRI showed AVN in all cases. Bilateral core decompression was performed in five cases (29.4%), total hip replacement in three cases (17.6%), and conservative treatment in nine cases (53%). The ongoing pandemic may have many long-term sequelae. There is a risk of developing AVN after COVID-19.

The incidence and risk factors for femoral head necrosis after femoral neck fracture in pediatric patients: a systematic review and meta-analysis

BackgroundThe incidence of avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) in the literature varies widely, and the risk factors associated with AVN after PFNF are controversial. Therefore, this study aimed to accurately investigate the incidence of AVN after PFNF and systematically evaluate and meta-classify their risk factors.MethodsA comprehensive search was performed of PubMed, Web of Science, and Embase. The pooled rate and 95% confidence interval (CI) were used to assess the incidence of AVN after PFNF, and pooled odds ratio (OR) were calculated to measure the effect sizes. In addition, we performed subgroup, stratified, and publication bias analyses.ResultsA total of 30 articles were included in our meta-analysis, with 303 AVN cases among 1185 patients. The pooled incidence of AVN after PFNF was 22% (95% CI 18%, 27%). Subgroup analyses indicated Delbet type I–IV fracture incidences with AVN of 45%, 32%, 17%, and 12%, respectively. The incidence of AVN after PFNF in Asia was 19%, lower than in Africa at 36%, Europe at 26%, and North America at 23%. In addition, the larger sample size group and the earlier published literature group showed a higher incidence of necrosis. Stratified analyses showed that patient age and Delbet fracture classification were both important factors affecting AVN after PFNF (OR = 1.61, p = 0.02 and OR = 3.02, p < 0.001, respectively), while the time to treatment was not (OR = 0.9, p = 0.71).ConclusionThe pooled incidence of AVN after PFNF was ~ 22%; furthermore, the available evidence demonstrates that patient age and Delbet type of fracture were important influencing factors of AVN after PFNF.

Avascular necrosis of the foot and ankle: aetiology, investigation and management

Avascular necrosis (AVN) of the foot and ankle can pose both a diagnostic challenge, and a management dilemma. This paper seeks to describe the various types of AVN in the foot and ankle and clarify the expected presentation, examination findings, investigations and management strategies available. In addition, discussion of the relevant basic sciences, and the process of bone healing will facilitate a broader understanding of the condition, and the risk factors for its development. AVN can be secondary to trauma, as in most cases of talar AVN, or secondary to factors such as steroid use, alcohol excess, metabolic diseases, repetitive microtrauma, and abnormal biomechanics. Usually, a combination of the above is thought to be responsible. Many of the conditions described are established in childhood, either presenting at the time, or in the third or fourth decade. Management ranges from exercise limitation and offloading footwear, to surgical decompression, osteotomy, fusion or excision. AVN has a high morbidity and affects a young demographic, causing a substantial burden on healthcare. Early recognition of symptoms, and appropriate investigation and management could reduce the number of patients progressing to advanced disease, avoiding the frequently unsatisfactory surgical outcomes associated with options such as fusion and excision.

Conversion Hip Arthroplasty Using Standard and Long Stems after Failed Internal Fixation of Intertrochanteric Fractures.

Failed internal fixation of intertrochanteric fractures (FIF-ITF) is often treated by conversion hip arthroplasty (CHA). This study aimed to evaluate the results and complications of using standard and long femoral stems in this operation. This retrospective, multi-center study enrolled 31 total hip arthroplasty (THA) and 23 hemiarthroplasties (HA) cases (30 women, 24 men; mean age 76 years) after FIF-ITF between 2012 and 2019, divided into two groups: standard stem group (n=20) and long stem group (n=34). The initial internal fixation includes 38 cases of proximal femoral nail anti-rotation (PFNA), eight cases of the dynamic hip screw (DHS), and eight cases of locking proximal femoral plate (LPFP). The indications for CHA included 38 cases of failure of fixation, seven cases of nonunion, and nine cases of avascular necrosis or posttraumatic osteoarthritis. Perioperative data and complications related to fracture and operation were collected, and preoperative and postoperative clinical and radiological data were analyzed. Clinical outcomes were assessed using Harris hip score (HHS) and 36-item Short Form survey (SF-36: including physical function (PF) score and body pain (BP) score). Statistical analyses were performed using the chi-square or Fisher's exact test, and the 2-sample t-test or Wilcoxon rank sum test. At an average of 5.6 years with a minimum of 2 years follow-up. A significant overall surgeon-related complication rate was detected (27.8% [15/54]), five cases had an intraoperative femur fracture, one case had a late periprosthetic femoral fracture, two cases had a stem penetration, one case had a cement leakage, and two patients had an early postoperative dislocation, one infection and three cases of stem loosening or subsidence. Long stems had an increased risk of complication (13/34) compared to standard stems (2/20) (P=0.031). The operation time and blood loss in the long stem group were higher than those in the standard stem group (P=0.002; 0.017). HHS and SF-36 significantly improved in both groups from preoperative to the final follow-up and did not present significant differences at the final follow-up (P > 0.05). CHA following FIF-ITF showed a successful mid-term clinical result, long stem arthroplasty should be approached with caution for the risks of higher complication rate, especially intraoperative femoral fractures.

Paediatric Femoral Diaphyseal Fractures in a South Wales Tertiary Centre: An Account of Trend in Management and Complications Over 16 Years.

Femoral shaft fractures in children have seen a number of interesting developments over the past 20 years. This is a retrospective cohort study looking into epidemiological and outcomes data of femoral shaft fractures in children treated at a tertiary centre in Wales from 2005-2021. Over a period of 16 years, there has been a significant increase in the number of rigid or elastic nailing and submuscular plating, coinciding with a dramatic reduction of external fixation for definitive treatment of diaphyseal femoral fractures. All patients above five years of age underwent operative fixation, with elastic or rigid intramedullary nailing the treatment of choice. Following multiple linear regression with 16 possible explanatory factors, this study found a statistically significant increase in time to union for open fractures, pre-operative translation, and operation time. Furthermore, there was a significant increase in post-operative leg length discrepancy for right versus left-sided fractures. Overall complication rates were 4% for minor and 8% for major complications. Complication rates were lowest for rigid intramedullary nailing and highest for external fixation. No cases of avascular necrosis were found for 27 rigid intramedullary nails inserted. Overall this study reports treatment choices and outcomes in keeping with current trends in management for paediatric femoral shaft fractures.

What are the surgical risks and 2-year stability of mandibular anterior subapical osteotomy in the treatment of dentoalveolar protrusion?

To investigate the stability and complications of mandibular anterior subapical osteotomy (ASO) in the treatment of bimaxillary dentoalveolar protrusion by way of a retrospective study. One hundred and twenty patients who received orthognathic surgery at a single center between 2008 and 2017 were included. Relapse was assessed by serial tracings of lateral cephalograms which were obtained pre-operatively (T1), within 6weeks after surgery (T2) and at 2years after surgery. The changes between T2 and T3 represented stability and were tested using the paired t test. The relationship between the extents of surgical repositioning (T2-T1) and relapse (T3-T2) was investigated using the Pearson correlation coefficient. The associations between the variables and the occurrence of relapse and complications identified the risk factors and were evaluated using the χ2 test or Fisher's exact test. When r > 0.80, clinical correlation was considered significant; and statistical significance was set at P < 0.05, while confidence interval was set at 95%. There was a mean uprighting of L1-MP by 12.7°. At 2years after surgery, 96.7% of the patients experienced a mean relapse of L1-MP by 2.9°. The extent of surgical repositioning was only weakly correlated with that of relapse and no specific factor that increased the risk of relapse could be identified. The most frequent complications were blood loss requiring transfusion, wound dehiscence or infection, gingival recession, and periodontal bone loss, involving 25.8 to 43.3% of the patients. The remaining complications included tooth root damage, fixation hardware exposure or infection, lingual mucosal laceration, and tooth devitalization. There were no cases of avascular necrosis or nonunion. Although relapse occurred in most of the patients after 2years, the actual extent was small (2.9°) which was not likely to be clinically significant. HKUCTR-2964 CLINICAL RELEVANCE: Although ASO may be valuable in correcting mandibular dentoalveolar protrusion, the procedure brings with it risks and complications and should be reserved for severe deformities.