Early Osteonecrosis Research Articles

Extracorporeal shock wave therapy with imaging examination for early osteonecrosis of the femoral head: a systematic review.

Extracorporeal shockwave therapy (ESWT) is a traditional non-invasive therapy to treat osteonecrosis of the femur head (ONFH). This systematic review aims to investigate whether ESWT can improve the clinical function of ONFH and whether differences in improvement can be observed in radiographic outcomes. Two authors independently searched PubMed, Embase, Cochrane Library, and Web of Science for English articles until October 21, 2023. After screening and reading the literature, the two authors independently used corresponding scales to evaluate the quality of the included articles and extracted data. The key data extracted included the Harris Hip Score (HHS), Visual Analog Scale (VAS), changes in lesion size, the change in the Association Research Circulation Osseous (ARCO) stage, and bone marrow edema stage. Nine articles included 468 males and 248 females. The average age was 43.29 years and the mean follow-up time was 15.19 months. After receiving ESWT, five studies involving 146 hips showed a higher HHS (MD=-33.38; 95%CI, -46.31, -20.45), and the difference was statistically significant (P<0.00001). The average VAS before treatment was above 5, but it dropped to 1.2 after ESWT (MD=4.64; 95%CI, 3.63, 5.64), and the difference was statistically significant (P<0.00001). Three studies found no significant differences in the areas of femoral head necrosis before and after treatment with ESWT(MD=9.66; 95%CI, -0.36, 19.67; P=0.06; I2=84%). Two articles showed that the use of ESWT had no significant effect on the change in the ARCO stage (MD=1.11; 95%CI, 0.76, 1.62; P=0.60; I2=0%). Three studies indicated that using ESWT could improve the bone marrow edema symptom in the early stage of ONFH (MD=4.35; 95%CI, 1.32, 14.37; P=0.02; I2=62%). Based on the current evidence, ESWT shows promise as a therapy to enhance hip function and alleviate pain in the early stage of ONFH. With the advancement of more precise imaging techniques, ESWT can potentially reduce the area affected by ONFH. However, such reduction was not found to be statistically significant at the imaging level. Additionally, ESWT could improve symptoms of bone marrow edema in the early stage. However, no significant change in ARCO grade was observed with ESWT treatment.

Zoledronic Acid and Enriched Autologous Bone Marrow Stem Cell Implantation for Femoral Head Osteonecrosis.

This study evaluated the clinical results of zoledronic acid in the treatment of early osteonecrosis of the femoral head (ONFH). Study retrospectively analyzed 60 patients with zoledronic acid with bone marrow stem cell(BMSC) implantation (The study group) and 64 patients with BMSC implantation (The control group). The primary evaluation index included VAS, HHS, collapsed rate, and total hip replacement arthroplasty (THA) conversion rate. The study group had a lower VAS (1.12 ± 0.22 vs 1.44 ± 0.32) and higher HHS (75.07 ± 3.66 vs 68.78 ± 2.24) compared to the control group in 6months after surgery (P < 0.05). In the study group, 12 hips (20%) collapsed, and 7 of 60 hips (11.67%) required THA surgery at the last follow-up. However, 25 hips (38.8%) collapsed in the control group, and 19 hips (29.69%) required THA surgery. The study group had a lower collapsed rate (P = 0.029) and THA conversion rate (P = 0.016) in survival analysis. Zoledronic acid and BMSC implantation in the treatment of early ONFH is safe and effective, reduces pain shortens recovery time, and reduces collapsed rate and THA conversion rate in ONFH patients.

A single sequence MRI-based deep learning radiomics model in the diagnosis of early osteonecrosis of femoral head.

The objective of this study was to create and assess a Deep Learning-Based Radiomics model using a single sequence MRI that could accurately predict early Femoral Head Osteonecrosis (ONFH). This is the first time such a model was used for the diagnosis of early ONFH. Its simpler than the previously published multi-sequence MRI radiomics based method, and it implements Deep learning to improve on radiomics. It has the potential to be highly beneficial in the early stages of diagnosis and treatment planning. MRI scans from 150 patients in total (80 healthy, 70 necrotic) were used, and split into training and testing sets in a 7:3 ratio. Handcrafted as well as deep learning features were retrieved from Tesla 2 weighted (T2W1) MRI slices. After a rigorous selection process, these features were used to construct three models: a Radiomics-based (Rad-model), a Deep Learning-based (DL-model), and a Deep Learning-based Radiomics (DLR-model). The performance of these models in predicting early ONFH was evaluated by comparing them using the receiver operating characteristic (ROC) and decision curve analysis (DCA). 1,197 handcrafted radiomics and 512 DL features were extracted then processed; after the final selection: 15 features were used for the Rad-model, 12 features for the DL-model, and only 9 features were selected for the DLR-model. The most effective algorithm that was used in all of the models was Logistic regression (LR). The Rad-model depicted good results outperforming the DL-model; AUC = 0.944 (95%CI, 0.862-1.000) and AUC = 0.930 (95%CI, 0.838-1.000) respectively. The DLR-model showed superior results to both Rad-model and the DL-model; AUC = 0.968 (95%CI, 0.909-1.000); and a sensitivity of 0.95 and specificity of 0.920. The DCA showed that DLR had a greater net clinical benefit in detecting early ONFH. Using a single sequence MRI scan, our work constructed and verified a Deep Learning-Based Radiomics Model for early ONFH diagnosis. This strategy outperformed a Deep learning technique based on Resnet18 and a model based on Radiomics. This straightforward method can offer essential diagnostic data promptly and enhance early therapy strategizing for individuals with ONFH, all while utilizing just one MRI sequence and a more standardized and objective interpretation of MRI images.

Systematic analysis of hip-preserving treatment for early osteonecrosis of the femoral head from the perspective of bibliometrics (2010–2023)

BackgroundOsteonecrosis of the femoral head (ONFH) is a serious condition that causes bone tissue death, femoral head collapse, and hip joint destruction. Early intervention through hip-preserving treatment is crucial to slow down disease progression, preserve hip joint function, and improve the quality of life of patients. We analyzed the knowledge map, research gaps, and future research directions in the field of hip-preserving treatment for early ONFH.MethodsAll publications related to hip-preserving treatment for early ONFH published between 2010 and 2023 were identified from the Web of Science Core Collection and analyzed using VOSviewer 1.6.19, CiteSpace 6.2.R2, and Scimago Graphica 1.0.35.ResultsIn total, 234 articles were analyzed. The results showed an exponential growth trend in the number of publications related to hip-preserving treatment for early ONFH in the past decade. China and the USA were the main contributors. International Orthopaedics published the most papers in this field, whereas Bone and Joint Surgery-American Volume had the highest average citation count per article. Several stable research topics were noted in this field, including core decompression (CD), osteotomy, bone transplantation in hip-preserving surgery, and cell therapy, which have become research hotspots in hip-preserving treatment.ConclusionsHip-preserving treatment for early ONFH has received increasing attention, and research in this field is expected to grow. Stable research topics include core decompression (CD), osteotomy, bone transplantation, and cell therapy. Future research is predicted to focus on cell therapy and combination therapy, resulting in an increasing number of publications on hip-preserving treatment for early ONFH.

Clinical application study of multiple small-diameter drilling combined with extracorporeal shock wave therapy (ESWT) under C-arm positioning in the treatment of early femoral head necrosis

To explore the therapeutic effect of multiple small diameter drilling combined with extracorporeal shock wave therapy (ESWT) under C-arm X-raylocalization in patients with early osteonecrosis of the femoral head (ONFH). A total of 106 cases of early ONFH patients admitted from May 2015 to May 2017 were retrospectively selected as the study subjects. According to different treatment methods, the patients were divided into observation group and control group, 53 cases in each group. The observation group was treated with multiple small-diameter drilling combined with ESWT under C-arm positioning in the observation group, including 41 males and 12 females with an age of (45.85±6.01) years old (22 to 70 years old);and the control group was treated with ESWT, including 34 males and 19 females with an age of (45.12±5.83) years old(20 to 68 years old) in the control group. The modified Harris hip scores(mHHS), visual analog scale(VAS), hip flexion range, hip abduction and adduction range, ONFH area ratio and clinical efficacy were compared between twe groups before and after treatment. Kaplan-Meier method was used to draw a survival curve to compare the femoral head survival rate between two groups during the 3-year follow-up period after treatment. There were no complications such as poor wound healing and infection. All of 106 patients were followed up for 28 to 36 months with an average of (31.06±4.28) months. MHHS score, hip flexion range and hip abduction and adduction range in the observation group were increased from (63.85±5.42) scores, (23.79±2.21) °, (32.40±4.19) ° before treatment to (85.51±5.69) scores, (34.65±2.73)°, (43.32±5.71)° at 2 years after treatment, respectively(P<0.05). The above indicators in the control group increased from (64.73±5.64)°, (23.82±2.18)°, (32.45±4.13)° before treatment to (81.65±5.48) scores, (32.79±2.87)°, (39.75±5.68)°at two years after treatment, respectively(P<0.05). VAS score and ONFH area ratio in the observation group decreased from (5.76±1.41) scores and (35.07±4.96)% before treatment to (3.39±1.02) scores and (22.04±3.23)% at 2 years after treatment, respectively(P<0.05). The above indicatiors in control group decreased from (5.73±1.45) scores and (35.24±5.18)% before treatment to (4.43±1.21) scores and (28.32±3.76)% at 2 years after treatment, respectively(P<0.05), and the improvement in the observation group was significantly higher than that in the control group(P<0.05). At 3 years after treatment, the femoral head survival rate in the observation group was higher than that in the control group (P<0.05). Multiple small diameter drilling combined with ESWT under C-arm positioning can significantly improve the clinical symptoms of patients with early ONFH, relieve pain and improve clinical efficacy.

Analysis of the efficacy of drilling decompression autologous bone marrow and allogeneic bone grafting in the treatment of HIV-positive patients with early osteonecrosis of the femoral head

ObjectiveTo investigate the efficacy of treating patients with HIV-positive osteonecrosis of the femoral head using drilled decompression autologous bone marrow and allogeneic bone grafting.Methods40 patients (44 hips) with early osteonecrosis of the femoral head treated by drilling decompression autologous bone marrow and allogeneic bone grafting since October 2015 were retrospectively analyzed, among which 20 patients (24 hips) were HIV-positive patients with early osteonecrosis of the femoral head, 16 males and 4 females, age 22–43 years, average 39.6 ± 10.18 years, and 20 patients (20 hips) in the same period HIV-negative early osteonecrosis of the femoral head patients, 13 males and 7 females, aged 48–78 years, mean 63.50 ± 7.94 years were negative controls. General information including ARCO stage, Harris score, VAS score, hematological indexes including CD4+ T lymphocyte count, and HIV viral load was recorded for all patients before surgery. All patients were operated on by drilling and decompression of the necrotic area, harvesting autologous iliac bone marrow with allogeneic bone, and bone grafting through the decompression channel. The patients were followed up regularly at 6, 12, and 24 months after surgery and annually thereafter, and the repair of the necrotic femoral head was observed by reviewing the frontal and lateral X-ray, CT or MRI of the hip joint, and the complications and functional recovery of the hip joint was counted and compared between the two groups.ResultsAll patients were followed up, and the ARCO stages in the HIV-positive group were stage I 2 hips, stage IIA 6 hips, stage IIB 8 hips, stage IIC 6 hips, and stage III 2 hips, with a follow-up time of 12 to 60 months and a mean of 24.6 months. In the negative control group, there were 3 hips in ARCO stage I, 7 hips in stage IIA, 5 hips in stage IIB, 3 hips in stage IIC, and 2 hips in stage III, and the follow-up time ranged from 13 to 62 months, with an average of 24.8 months. The Harris score and VAS score of the hip in both groups improved significantly at 6 months postoperatively compared with those before surgery (P < 0.001). The difference between the Harris score of the hip in the positive group at 24 months postoperatively compared with that at 6 months postoperatively was statistically significant, but the VAS score at 24 months postoperatively compared with that at 6 months postoperatively was not statistically significant. In the negative group, there was no statistically significant difference in the Harris score and VAS score of the hip at 24 months postoperatively compared with those at 6 months postoperatively. In the positive group, there was a trend of continuous increase in hip BMD from the beginning of the postoperative period (P < 0.001). There was no statistically significant difference between the negative group and the positive group at the 24 months postoperatively follow-up except for the Harris score, which was statistically significant (P < 0.001), and the VAS score, which was statistically insignificant. At the 24 months postoperatively follow-up, patients in both groups had good recovery of hip function, and no complications such as vascular and nerve injury and fracture occurred during the perioperative period and follow-up period, and no complications related to incisional infection and pulmonary infection occurred during hospitalization.ConclusionThe treatment of early HIV-positive osteonecrosis of the femoral head patients with autologous bone marrow and allogeneic bone grafting by drilling and decompression to remove the tissue in the necrotic area of the femoral head can effectively stop the process of osteonecrosis of the femoral head and promoting femoral head repair in HIV-positive patients is a safe and effective method for treating HIV-positive patients with early osteonecrosis of the femoral head, and can effectively delay or postpone total hip replacement in patients.

WITHDRAWN: Analysis of the Efficacy of Drilling Decompression Autologous Bone Marrow and Allogeneic Bone Grafting in the Treatment of HIV-positive Patients with Early Osteonecrosis of the Femoral Head

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Application of biomaterials in treating early osteonecrosis of the femoral head: Research progress and future perspectives.

Osteonecrosis of the femoral head (ONFH), a progressive pathological process of femoral head ischemia and osteocyte necrosis, is a refractory orthopedic disease caused by multiple etiologies and there is no complete cure at present. With the extension of ONFH duration, osteocyte apoptosis and trabecular bone loss can decrease the load-bearing capacity of the femoral head, which leads to the collapse of the articular cartilage and subchondral bone. Therefore, an urgent clinical need exists to develop effective treatment strategies of early-stage ONFH for maintaining the hip joint function and preventing femoral head collapse. In recent years, extensive attention has been paid to the application of diverse biomaterials in treating early ONFH for sustaining the normal morphology and function of the autologous femoral head, and slowing disease progression. Herein, we review the research progress of bone grafts, metallic materials, bioceramics, bioglasses and polymer materials for early ONFH treatment, and discuss the biological mechanisms of bone repair and regeneration in the femoral-head necrotic area. We propose suggestions for future research directions, from a special perspective of improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts (VAOs) generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts (BAOs) and BAO-mediated bone resorption. This review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH. STATEMENT OF SIGNIFICANCE: We believe that at least three aspects of this manuscript make it interesting to readers of the Acta Biomaterialia. First, we briefly summarize the incidence, pathogenesis, risk factors, classification criteria and treatment of early osteonecrosis of the femoral head (ONFH). Second, we review the research progress in biomaterials for early ONFH treatment and the biological mechanisms of bone repair and regeneration in femoral-head necrotic area. Third, we propose future research progress on improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts and bone resorption. We hope this review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH.

Age is predictive of higher rate of conversion to total hip arthroplasty after core decompression for osteonecrosis of the hip

BackgroundCore decompression may be performed for early osteonecrosis with a goal of improving symptoms and potentially delaying the need for total hip arthroplasty. The effectiveness and complication rate of this procedure is not well understood given the relatively rare nature of hip osteonecrosis. PurposeThe purpose of this study is to determine time to total hip arthroplasty (THA) after core compression, assess predictors of early conversion to THA, and to examine complications after hip core decompressions. MethodsUsing Current Procedural Terminology (CPT) codes, we queried the Mariner PearlDiver dataset for patients who underwent hip core decompression. Patient demographics were recorded and subsequent THA conversion within 2 years after surgery were tracked. Patient demographic factors, including age, sex, obesity, diabetes, prior fractures, steroid use, tobacco use, or alcohol use, were evaluated as possible predictors of early conversion to THA. International Classification of Diseases (ICD) codes were used to identify complications at 90 days after core decompression. Multiple linear regression was used to test if the patient demographics significantly predicted conversion to THA and complications after core decompression. ResultsBetween 2010 and 2020, 555 patients underwent hip core decompression. Within 2 years of core decompression, 226 patients converted to THA (40.7%). Age was the only significant risk factor for conversion to THA. The highest proportion of patients (61.1%, 138/226) who converted to THA were between age 40–59. The 90-day complication rate was 2.9% (16/555). The most common complication was femoral neck fracture (11/16 of all complications). DiscussionThere is a high failure rate following core decompression for hip osteonecrosis with over one third of patients converting to THA within 2 years. Age was the only variable predictive of conversion to THA. The overall complication rate after core decompression is low at 90 days. ConclusionPatients should be counseled regarding the risk of early conversion to THA if over 40 and the potential risk of femoral neck fracture.

Detection of Subchondral Bone Microcirculatory Perfusion in Adults with Early Osteonecrosis of the Femoral Head Using Contrast-Enhanced Ultrasound: A Prospective Study.

The aim of this study was to quantitatively assess subchondral bone microcirculation perfusion in adults with early osteonecrosis of the femoral head (ONFH) using contrast-enhanced ultrasound (CEUS) and to evaluate its correlation with the Association Research Circulation Osseous (ARCO) stage. We investigated 97 adult patients with definite ONFH by imaging a total of 155 hips, performing CEUS, storing images of CEUS processes at different ARCO stages and generating CEUS time-intensity curves (TICs) to obtain perfusion parameters. Differences in CEUS parameters at different ARCO stages were analyzed, and correlations were explored. A logistic regression model was constructed by incorporating the meaningful CEUS indicators. The CEUS parameters time to peak (TTP), peak intensity (PI), enhanced intensity (EI), ascending slope (AS), descending slope (DS) and area under the receiver operating characteristic curve (AUC) were significantly different in ARCO stage Ⅰ compared with stage ⅢA, and the same results were obtained in stage Ⅱ compared with stage ⅢA. However, there were no significant differences between stages Ⅰ and Ⅱ. The MTT (mean transit time) assay was not significantly different between the different stages. The receiver operating characteristic curve analysis of TTP, PI, EI, AS, DS and AUC in stages Ⅰ and ⅢA had a certain diagnostic efficacy, similar to the results in stages Ⅱ and ⅢA. The diagnostic performance of DS was less accurate in stages Ⅰ and ⅢA, while the diagnostic performance of TTP was less accurate in stages Ⅱ and ⅢA. ARCO stage was independently and negatively correlated with TTP and DS and independently and positively correlated with PI, EI, AS and AUC. The MTT assay was not correlated with ARCO stage. Logistic regression models containing statistically significant TTP, EI and AUC values were constructed, and all three values were closely related to the ARCO stage. In patients with different ARCO stages of ONFH, CEUS can effectively assess subchondral bone perfusion of the femoral head and is expected to become an effective imaging method for the diagnosis of early ONFH.

Quantitative analysis of local microcirculation changes in early osteonecrosis of femoral head: DCE-MRI findings.

This study aims to quantitatively analyze the changes in local microcirculation in early osteonecrosis of the femoral head (ONFH) by dynamic contrast-enhanced (DCE) MRI and to explore the pathophysiological mechanisms of early ONFH. We selected 49 patients (98 hips) aged 21-59years who were clinically diagnosed with early ONFH. A total of 77 femoral heads were diagnosed with different degrees of necrosis according to the Association Research Circulation Osseous (ARCO) staging system, and 21 femoral heads were judged to be completely healthy. All patients underwent DCE-MRI scanning. Pseudocolor images and time-signal intensity curves were generated by Tissue 4D processing software. The volume transfer constant (K trans), extracellular extravascular space, also known as vascular leakage (V e), and transfer rate constant (K ep) of healthy and different areas of necrotic femoral heads were measured on perfusion parameter maps. The differences and characteristics of these parameters in healthy and different areas of necrotic femoral heads were analyzed. The signal accumulation in healthy femoral heads is lower than that of necrotic femoral heads in pseudocolor images. The time-signal intensity curve of healthy femoral heads is along the horizontal direction, while they all have upward trends for different areas of necrotic femoral heads. The mean value of K trans of healthy femoral heads was lower than the integration of necrotic, boundary, and other areas (F = 3.133, P = .036). The K ep value of healthy femoral heads was higher than the integration of lesion areas (F = 6.273, P = .001). The mean V e value of healthy femoral heads was smaller than that of the lesion areas (F = 3.872, P = .016). The comparisons of parameters between different areas and comparisons among healthy areas and lesion areas showed different results. ONFH is a complex ischemic lesion caused by changes in local microcirculation. It mainly manifests as increased permeability of the vascular wall, blood stasis in the posterior circulation, high intraosseous pressure in the femoral head, and decreased arterial blood flow. The application of DCE-MRI scanning to quantitatively analyze the visual manifestations of microcirculation after early ONFH is an ideal method to study the microcirculation changes of necrotic femoral heads.

Effect of three clinical therapies on cytokines modulation in the hip articular cartilage and bone improvement in rat early osteonecrosis of the femoral head

BackgroundExtracorporeal shockwave therapy (ESWT) and adipose-derived mesenchymal stem cells (ADSCs) have been used clinically for the treatment of osteonecrosis of the femoral head (ONFH). The study elucidated that ESWT, ADSCs, and combination therapy modulated pro-inflammatory cytokines in the articular cartilage and subchondral bone of early rat ONFH. MethodsESWT and ADSCs were prepared and isolated for treatment. Micro-CT, pathological analysis, and immunohistochemistry were performed and analysed. ResultsAfter treatments, subchondral bone of ONFH was improved in trabecular bone volume (BV/TV) (p < 0.001), thickness (Tb.Th) (p < 0.01 and 0.001), and separation (Tb.Sp) (p < 0.001) and bone mineral density (BMD) (p < 0.001) using micro-CT analysis. The articular cartilage was protected and decreased apoptosis markers after all the treatments. The expression of IL33 (p < 0.001), IL5 (p < 0.001), IL6 (p < 0.001), and IL17A (p < 0.01) was significantly decreased in the ESWT, ADSCs, and Combination groups as compared with ONFH group. The IL33 receptor ST2 was significantly increased after treatment (p < 0.001) as compared with ONFH group. The Combination group (p < 0.01) decreased the expression of IL6 better than the ESWT and ADSCs groups. ConclusionESWT, ADSCs and combination therapy significantly protected articular cartilage and subchondral bone of early rat ONFH by modulating the expression of pro-inflammatory cytokines including, IL33 and its receptor ST2, IL5, IL6, and IL17A.

Deep Learning Approach for Diagnosing Early Osteonecrosis of the Femoral Head Based on Magnetic Resonance Imaging

BackgroundThe diagnosis of early osteonecrosis of the femoral head (ONFH) based on magnetic resonance imaging (MRI) is challenging due to variability in the surgeon’s experience level. This study developed an MRI-based deep learning system to detect early ONFH and evaluated its feasibility in the clinic. MethodsWe retrospectively evaluated clinical MRIs of the hips that were performed in our institution from January 2019 to June 2022 and collected all MRIs diagnosed with early ONFH. An advanced convolutional neural network (CNN) was trained and optimized; then, the diagnostic performance of the CNN was evaluated according to its accuracy, sensitivity, and specificity. We also further compared the CNN’s performance with that of orthopaedic surgeons. ResultsOverall, 11,061 images were retrospectively included in the present study and were divided into three datasets with ratio 7:2:1. The area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity of the CNN model for identifying early ONFH were 0.98, 98.4, 97.6, and 98.6%, respectively. In our review panel, the averaged accuracy, sensitivity, and specificity for identifying ONFH were 91.7, 87.0, and 94.1% for attending orthopaedic surgeons; 87.1, 84.0, and 89.3% for resident orthopaedic surgeons; and 97.1, 96.0, and 97.9% for deputy chief orthopaedic surgeons, respectively. ConclusionThe deep learning system showed a comparable performance to that of deputy chief orthopaedic surgeons in identifying early ONFH. The success of deep learning diagnosis of ONFH might be conducive to assisting less-experienced surgeons, especially in large-scale medical imaging screening and community scenarios lacking consulting experts.

Biomechanical analysis of the drilling parameters for early osteonecrosis of the femoral head

Background and objectiveCore decompression is a surgical procedure commonly used to treat the early osteonecrosis of the femoral head. However, It is not known whether different drilling parameters affect postoperative biomechanical strength. This study aimed to analyze the mechanical stability of different drilling locations and diameters of core decompression using finite element analysis. MethodsFinite element models were established based on computed tomography images obtained from five healthy participants, including the different drilling locations (Lesser trochanter: Above, Parallel, and Below) and diameters. Biomechanical parameters including stiffness and stress were evaluated under slow running loads. ResultsAt the same drilling diameter, the femoral stiffness was highest (p < 0.05) in the Above group and lowest in the Below group, while the maximum equivalent stress of the entry area and the necrotic area was highest (p < 0.05) in the Below group and lowest in the Above group. With the increase of drilling diameters, the stiffness decreased and its decreased percentage comparing the preoperative: Above (1.06–8.82%), Parallel (2.51–13.61%), and Below (3.99–15.06%). The maximum equivalent stress of the entry area and necrotic area increased as the drilling diameter increased, and its increased percentage comparing the preoperative, for the entry area: Above (14.11–219.58%), Parallel (35.91–306.37%), and Below (46.12–240.98%); for the necrotic area: Above (13.64–114.69%), Parallel (29.37–187.76%), and Below (44.76–202.10%). The range of safety drilling parameters (SDP) was obtained (Below<9 mm, Parallel<11 mm, and Above<13 mm) by comparing the maximum equivalent stress of two areas and its yield strength. For patients of different sizes and normal bone mineral density (BMD), the maximum equivalent stress of the two areas did not exceed its yield strength using the range of SDP, except for the patients with abnormal BMD (Osteoporosis) or high body mass index (BMI≥28 kg/m2). ConclusionsThe biomechanical properties of early osteonecrosis of the femoral head deceased with increasing drilling diameters parameters, especially at the location below the lesser trochanter. The SDP (Below<9 mm, Parallel<11 mm, and Above<13 mm) is a suitable reference for most patients to perform slow running postoperatively, while it may be not suitable for patients with osteoporosis or obesity.

Analysis of peripheral bone reconstruction after the failure of hip osteonecrosis treatment with porous tantalum rod implantation.

Failure of porous tantalum rod (PTR) implantation in treating early osteonecrosis of femoral head (ONFH) has been frequently reported, but the underlying mechanism remains uncertain, which raised the concern of its efficacy. The study aimed to discuss the underlying mechanism from the perspectives of bone reconstruction and pathological changes. Five patients with PTR implantation experienced total hip arthroplasty (THA) due to recurrent pain, whose femoral heads were collected as "tantalum group." Normal (fracture) and necrotic femoral heads were respectively collected (both n = 5) after THA. The bone quality and structure, biomechanical properties, and histopathological features were analyzed by micro-CT scanning, mechanical measurement, and histological examination. Both the tantalum group and necrotic group had significantly poorer bone quantity and quality than the normal group. Three-dimensional imaging reconstruction showed that the trabeculae of the tantalum group were poorest in quality. Significant differences in terms of bone quality, structure, and biomechanical properties were present between the inside and outside regions around PTR, which revealed abnormal bone reconstruction. Biomechanical analysis revealed inferior properties in the tantalum group and necrosis group. H&E staining demonstrated neutrophil infiltration among the peripheral trabeculae around PTR, and the inflammation cells were significantly more abundant than that in the normal and necrosis groups. Abnormal bone reconstruction around PTR was an important cause for failure of PTR implantation in the treatment of ONFH, which was related to biomechanical stress distribution and chronic inflammation infiltration. Insufficient biomechanical support and inflammatory trabeculae edema might account for the recurrent pain.

Three-dimensional printing-assisted rotational osteotomy of the femoral neck in the treatment of early osteonecrosis of the femoral head

Rotational osteotomy of the base of the femoral neck involves osteotomy at the intertrochanteric level and rotation of the femoral head. That is to rotate the avascular collapse of the femoral head to the nonweight-bearing area of the hip joint, thus effectively avoiding further collapse of the femoral head necrosis. Clinical has achieved a certain effect. However, there are also some problems in the operation, such as the individual difference of the neck-shaft angle and the anteversion angle of the femoral neck of the affected hip joint among different patients, the nonunion of the osteotomy end, the mismatch of the relationship between the head and the acetabulum, and the direction and angle of the head rotation. The combined three-dimensional printing technology is expected to ensure the accuracy of osteotomy, to solve the adverse complications, and to improve the surgical efficacy.

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.

Minimally invasive surgical treatment of brucellar osteoarthritis complicated with early osteonecrosis of femoral head

Minimally invasive surgical treatment of brucellar osteoarthritis complicated with early osteonecrosis of femoral head

Biofunctionalized composite scaffold to potentiate osteoconduction, angiogenesis, and favorable metabolic microenvironment for osteonecrosis therapy

Osteonecrosis is a common orthopedic disease in clinic, resulting in joint collapse if no appropriate treatment is performed in time. Core decompression is a general treatment modality for early osteonecrosis. However, effective bone regeneration in the necrotic area is still a significant challenge. This study developed a biofunctionalized composite scaffold (PLGA/nHA30VEGF) for osteonecrosis therapy through potentiation of osteoconduction, angiogenesis, and a favorable metabolic microenvironment. The composite scaffold had a porosity of 87.7% and compressive strength of 8.9 MPa. PLGA/nHA30VEGF had an average pore size of 227.6 μm and a water contact angle of 56.5° with a sustained release profile of vascular endothelial growth factor (VEGF). After the implantation of PLGA/nHA30VEGF, various osteogenic and angiogenic biomarkers were upregulated by 2–9 fold compared with no treatment. Additionally, the metabolomic and lipidomic profiling studies demonstrated that PLGA/nHA30VEGF effectively regulated the multiple metabolites and more than 20 inordinate metabolic pathways in osteonecrosis. The excellent performances reveal that the biofunctionalized composite scaffold provides an advanced adjuvant therapy modality for osteonecrosis.

Clinical study on new risk assessment and prediction system for early osteonecrosis of the femoral head

To establish a risk assessment and prediction system for early osteonecrosis of the femoral head (ONFH) in order to predict the collapse risk. The risk assessment system for early necrosis and collapse of femoral head was established based on the combination of Steinberg stage, ABC typing and the proportion of the proximal sclerotic rim. Firstly, Steinberg stage system was applied. ABC typing was applied to predict risk in stage I, type C was risk free, type B was low risk, type A and type BC were medium risk, type A-C and type AB were high risk. The classification of proximal sclerotic rim was first applied when the Steinberg stage was Ⅱ-Ⅲ, and type 2 was expected to be low risk. If the classification of proximal sclerotic rimwas type 1, then the ABC typing was applied, type C was risk-free, type B was low risk, type A and type BC were medium risk, type A-C and type AB were high risk. According to this prediction system, the collapse risk of femoral head in 188 cases(301 hips) were predicted by retrospective analysis. All the hips were enrolled at the out-patient department of orthopedic in Guang'anmen Hospital attached to China Academy of Chinese Medical Science. The consistency of the prediction results of three doctors and one doctor at different times were evaluated. Among them, 136 cases were male, 52 were female. 75 cases were single hip, 113 were double hip. The age of the patients wa 19 to 64(42.61±12.07) years. The natural course of disease was 0.33 to 5.00(3.62±1.93) years. 206 hips in 301 hips had collapsed, with a collapse rate of 68.44%. In the risk-free group, none hip had collapsed, with a collapse rate of 0%. In the low-risk group, 9 hip in 91 hips had collapsed, with a collapse rate of 9.89%. In the medium-risk group, 12 hip in 19 hips had collapsed, with a collapse rate of 63.16%. And in the high risk group, 185 hips in 190 hips had collapsed, with a collapse rate of 97.37%. They were significantly differences in their collapse rate (P=0.00) in the following order:high-risk group> medium-risk > low-risk group > risk-free group. The prediction value of the system was high (AUC=0.95, P=0.00). The results predicted by different doctors were consistent (ICC=0.94, P=0.00), and the results predicted by the same doctor at two different times were consistent (Kappa coefficient =0.90, P=0.00). The risk assessment and prediction system for early ONFH selects different methods to predict the risk of collapse according to the imaging characteristics of different stages, which is combines with the comprehensive assessment of multiple risk factors. The system is applicable to a wide range, simple operation and convenient for clinical application.