Destruction Of Femoral Head Research Articles

Elucidating the role of the GC/GR/GLUT1 axis in steroid-induced osteonecrosis of the femoral head: A proteomic approach

BackgroundSteroid-induced osteonecrosis of the femoral head (SONFH) is a prevalent and incapacitating condition that affects the hip joint. Unfortunately, early diagnostic and treatment measures are limited. MethodsOur study employed Tandem Mass Tag (TMT) labeling mass spectrometry (MS)-based quantitative proteome to compare the proteins of femoral head tissues in patients with SONFH with those of patients who sustained femoral neck fracture (FNF). We investigated the level and effects of glucose transporter member 1 (GLUT1) in SONFH patients and MC3T3-E1 cells and examined the function and molecular mechanism of GLUT1 in the context of SONFH using in vivo and in vitro approaches. ResultsThe SONFH group exhibited significant changes in protein expression levels compared to the fracture group. Specifically, we observed the up-regulation of 86 proteins and the down-regulation of 138 proteins in the SONFH group. Among the differentially expressed proteins, GLUT1 was down-regulated and associated with glucose metabolic processes in the SONFH group. Further analysis using Parallel Reaction Monitoring (PRM), WB, and PCR confirmed that the protein was significantly down-regulated in both femoral head tissue samples from SONFH patients and dexamethasone-treated MC3T3-E1 cells. Moreover, overexpression of GLUT1 effectively reduced glucocorticoid (GC)-induced apoptosis and the suppression of osteoblast proliferation and osteogenic differentiation in MC3T3-E1 cells, as well as GC-induced femoral head destruction in GC-induced ONFH rat models. Additionally, our research demonstrated that GC down-regulated GLUT1 transcription via glucocorticoid receptors in MC3T3-E1 cells. ConclusionsGLUT1 was down-regulated in patients with SONFH; furthermore, down-regulated GLUT1 promoted apoptosis and inhibited osteoblast ossification in dexamethasone-induced MC3T3-E1 cells and contributed to GC-induced femoral head destruction in a SONFH rat model. Glucocorticoids inhibited the transcriptional activity of GLUT1, leading to a reduction in the amount and activity of GLUT1 in the cells and ultimately promoting apoptosis and inhibiting osteoblast ossification via the GC/GR/GLUT1 axis in SONFH.

STAT3 ACTIVATION IN THE SYNOVIAL TISSUES FROM THE HIP JOINT IN THE EARLY STAGE OF RAPIDLY DESTRUCTIVE COXOPATHY

The interleukin-6/gp130-associated Janus Kinases/STAT3 axis is known to play an important role in mediating inflammatory signals, resulting in production of matrix metalloproteinase-3 (MMP-3). The hip joints with rapidly destructive coxopathy (RDC) demonstrate rapid chondrolysis, probably by increased production of MMP-3 observed in the early stage of RDC. In the recent study, no apparent activation of STAT3 has been shown in the synovial tissues obtained from the osteoarthritic joint at operation. However, no data are currently available on STAT3 activation in the synovial tissues in the early stage of RDC. This study aimed to elucidate STAT3 activation in the synovial tissues in the early stage of RDC. Synovial tissues within 7 months from the disease onset were obtained from four RDC patients with femoral head destruction and high serum levels of MMP-3. RDC synovial tissues showed the synovial lining hyperplasia with an increase of CD68-positive macrophages and CD3-positive T lymphocytes. STAT3 phosphorylation was found in the synovial tissues by immunohistochemistry using anti-phospho-STAT3 antibody. The majority of phospho-STAT3-positive cells were the synovial lining cells and exhibited negative expression of macrophage or T cell marker. Treatment with tofacitinib, a Janus Kinase inhibitor, resulted in a decrease in phospho-STAT3-positive cells, especially with high intensity, indicating effective suppression of STAT3 activation in RDC synovial tissues. Inhibitory effect of tofacitinib could act through the Janus Kinase/STAT3 axis in the synovial tissues in the early stage of RDC. Therefore, STAT3 may be a potential therapeutic target for prevention of joint structural damage in RDC.Acknowledgements: This study was supported by Katakami Foundation for Clinical Research.

Activation of STAT3 (signal transducer and activator of transcription 3) in synovial tissues from the hip joint in the early stage of rapidly destructive coxopathy.

Interleukin-6 signaling activates signal transducer and activator of transcription 3 (STAT3), resulting in matrix metalloproteinase-3 (MMP-3) production. The hip joints with rapidly destructive coxopathy (RDC) show rapid chondrolysis, probably by increased MMP-3. This study aimed to elucidate STAT3 activation in the synovial tissues with joint destruction in the early stage of RDC. Synovial tissues within 7 months from the disease onset were obtained from four RDC patients with femoral head destruction and high serum levels of MMP-3. RDC synovial tissues demonstrated the synovial lining hyperplasia with an increase of CD68-positive macrophages and CD3-positive T lymphocytes. STAT3 activation was found in the synovial tissues by immunohistochemistry using anti-phospho-STAT3 antibody. The majority of phospho-STAT3-positive cells were the synovial lining cells and exhibited negative expression of the macrophage or T cell marker. Treatment with CP690,550, a Janus Kinase inhibitor, resulted in a decrease in phospho-STAT3-positive cells, especially with high intensity, indicating effective suppression of STAT3 activation in RDC synovial tissues. Inhibitory effect of CP690,550 could work through the Janus Kinase/STAT3 axis in the synovial tissues in the early stage of RDC. Thus, STAT3 may be a potential therapeutic target for prevention of joint structural damage in RDC.

A 5-year follow-up of Girdlestone resection arthroplasty in hip infection continued by Total hip replacement: A case report.

IntroductionResection arthroplasty of the hip was already performed for recent 100 years. This kind of surgery has been used for a wide variety of hip problems such as infection, degenerative osteoarthritis and prosthetic joint infection. Total hip replacement is remarkable procedure in order to relieve pain and restore hip function. We present this report to describe our experience in treating hip infection by used two stages of surgery.Case presentationA 61-years old male suffered left hip infection that leads severe destruction on his joint. He felt badly pain on his hip with significant disability associated it such as limping, restriction of movements, and shortening of the limb. The hip movements were painful and caused walking in antalgic gait. Radiologic examination at that time revealed gross destruction of femoral head as well as acetabulum, irregular and hazy joint margins with diminished joint space. Patient was diagnosed with chronic non-specific inflammation of the hip joint.ResultTwo stages surgery were performed on this patient. Resection arthroplasty firstly performed in order to eradicate the infection completely and alleviate very bothersome pain for improvement of patient's quality of life. Two years later, after patient was ready for next stage mentally, cemented total hip replacement performed to achieve normal function of the hip. Five-years follow up functional outcome was performed. Patient was very satisfied with the result with Harris hip scores was 95.ConclusionResection arthroplasty of the hip followed by a conversion to total hip replacement in hip infection case provide complete infection eradication, good functional outcome and satisfaction for the patient. Although the procedure was time-consuming it can be a choice if the eradication of infection still in a doubt.

Association between sagittal spinopelvic alignment and femoral head destruction in the early stage of rapidly destructive coxopathy.

AimsThis study aimed to evaluate sagittal spinopelvic alignment (SSPA) in the early stage of rapidly destructive coxopathy (RDC) compared with hip osteoarthritis (HOA), and to identify risk factors of SSPA for destruction of the femoral head within 12 months after the disease onset.MethodsThis study enrolled 34 RDC patients with joint space narrowing > 2 mm within 12 months after the onset of hip pain and 25 HOA patients showing femoral head destruction. Sharp angle was measured for acetabular coverage evaluation. Femoral head collapse ratio was calculated for assessment of the extent of femoral head collapse by RDC. The following parameters of SSPA were evaluated using the whole spinopelvic radiograph: pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), sagittal vertical axis (SVA), thoracic kyphosis angle (TK), lumbar lordosis angle (LL), and PI-LL.ResultsThe HOA group showed higher Sharp angles compared with the RDC group. PT and PI-LL were higher in the RDC group than the HOA group. SS and LL were lower in the RDC group than the HOA group. No difference was found in PI, SVA, or TK between the groups. Femoral head collapse ratio was associated with PT, SS, SVA, LL, and PI-LL. A PI-LL > 20° and a PT > 30° correlated with greater extent of femoral head destruction by RDC. From regression analysis, SS and SVA were significantly associated with the femoral head collapse ratio within 12 months after disease onset.ConclusionCompared with HOA, RDC in the early stage correlated with sagittal spinopelvic malalignment. SS and SVA may partially contribute to the extent of femoral head destruction by RDC within 12 months after the onset of hip pain. The present study indicates a potential role of SSPA assessment in identification of RDC patients at risk for subsequent bone destruction.Cite this article: Bone Jt Open 2022;3(1):77–84.

Primum Non Nocere: Is It Really True with Corticosteroid Hip Injections?

Commentary The article by Okike et al. provides new data on rapidly destructive hip disease (RDHD) following intra-articular corticosteroid (IACS) injection of the hip. The risk of an adverse effect on joints by local injections of corticosteroids was mentioned as early as 1951 by Hollander1, but corticosteroid hip injections were very rare during that period. RDHD (50% articular space narrowing in 1 year or femoral head destruction of >2 mm in 1 year) was first described by Forestier in 19572, and RDHD was only reported as an independent disease by Lequesne2 in 1970. As RDHD can be associated with other diseases (e.g., rheumatoid arthritis, chondrocalcinosis, amyloidosis, etc.), and as intra-articular injection of corticosteroids in the hip was uncommon before 1990, the relationship between these 2 events has remained highly debated and contested. After 2000, IACS injections increased in frequency for pain relief and theoretically for postponing total hip arthroplasty (THA) in cases of osteoarthritis (OA) or osteonecrosis. Several recent reports3 have suggested that these injections are associated with adverse events, particularly the paradoxical risk of accelerating the need for arthroplasty. The mystery has been partly solved by Okike et al., whose study confirmed these adverse effects and showed that the risk is related to the dose. Specifically, the authors reported a low risk of RDHD following a single low-dose (≤40-mg) triamcinolone injection but noted a high risk following a high-dose (≥80-mg) injection and multiple injections. What are the lessons that should be drawn from this article? Intra-articular injection represents the most invasive mode of nonoperative treatment that is used for the relief of pain in patients who have not responded to other conservative therapeutic modalities. The adverse effects of systemic corticosteroid therapy on bone, particularly the risk of hip osteonecrosis, are well known. Local injections of corticosteroids are generally considered safe, although they are known to be chondrotoxic4, probably by affecting the proteins of the cartilage, especially aggrecan, type-II collagen, and proteoglycan. Apart from RDHD, other side effects that have been described in association with hip corticosteroid injections include subchondral insufficiency fracture, osteonecrosis, and accelerated OA progression3. Therefore, corticosteroids are probably not as safe as we thought, when injected in the hip. Their use should be decreased, and the indications for hip injections (if any) should be limited. First, it must be remembered that there are other injectable products that may have an analgesic effect, including mesenchymal stem cells, hyaluronic acid, and platelet-rich plasma. Even if these products are often used for symptomatic relief rather than disease reversal, no risk of rapid destruction of a joint has been reported in association with these products. Unlike local corticosteroids, they conform to the old adage “primum non nocere,” and some regenerative potential has been demonstrated, at least in the knee5. Second, when corticosteroid hip injection is performed, the dose and the number of injections should be scrutinized and imaging should be obtained. If IACS injection is performed with ultrasound guidance, clinicians should consider obtaining repeat radiographs, before and after corticosteroid injections, in order to evaluate for eventual narrowing of the joint space. Furthermore, a normal radiograph associated with severe joint pain should lead to pre-injection magnetic resonance imaging to detect hip osteonecrosis, labral abnormality, or subchondral insufficiency fracture. Third, the severity of hip disease should be analyzed before corticosteroid hip injection. Patients with collapsed osteonecrosis or severe OA could be candidates for a limited number of low-dose IACS injections, given that THA would be their only other option to relieve pain. However, when a patient with early hip OA or with hip osteonecrosis without collapse is referred for corticosteroid injection, the patient should be informed about the risk of accelerating the disease, with worsening pain and a possible need for a premature THA to relieve pain. In conclusion, corticosteroid injections are frequently performed in the hip with the hope of relieving pain and of postponing THA. However, the article by Okike et al. should lead to a careful reconsideration of the routine use of corticosteroid hip injection.

Destructive Arthropathy of the Femoral Head

Destructive arthropathy of the hip refers to noninfectious arthropathy causing extensive femoral head bone destruction. It has been described in the surgical literature using a variety of diagnostic criteria, but it remains a poorly defined entity. Cases of destructive arthropathy diagnosed at our institution between July 1, 2015, and December 31, 2019, were identified by a free text search of the radiology database. The medical record of each case was reviewed for possible causes of femoral head destruction, clinical presentation, laboratory values, imaging studies, and pathologic diagnoses. Imaging studies and pathology specimens were retrospectively reviewed. Twenty femoral heads were identified in which there was 25% or greater destruction of the femoral head in the absence of infections, congenital disease, or inflammatory arthritis. Destructive arthropathy was characterized pathologically by fibromyxoid change of the marrow, aggregates of necrotic bone fragments, increased numbers of osteoclasts, increased trabecular destruction, and granuloma-like aggregates. The histologic findings were distinctive. We postulate that a variety of preexisting conditions set in motion a cascade of tissue factors that led to bone destruction.

Bone turnover markers in the early stage of rapidly progressive osteoarthritis of the hip.

Previous reports have demonstrated that patients with end-stage rapidly progressive osteoarthritis of the hip (RPOH) show significantly higher serum levels of bone turnover markers than those with osteoarthritis (OA). However, the characteristics of bone turnover markers in the early stage of RPOH remain unclear. This study aimed to elucidate the association of bone turnover markers with disease progression in the early stage of RPOH. This study included 29 postmenopausal female patients with joint space narrowing >2 mm demonstrated on a series of radiographs and computed tomography within 1 year following the onset of hip pain. The study also included 9 postmenopausal female patients with hip OA secondary to developmental dysplasia showing femoral head destruction. Cortical thickness index (CTI) associated with bone mineral density of the hip was analyzed. Serum concentrations of tartrate-resistant acid phosphatase-5b (TRACP-5b) and bone alkaline phosphatase (BAP) were evaluated. RPOH was classified into two types on the basis of the absence (type 1, n=13) or presence (type 2, n=16) of subsequent destruction of the femoral head within 1 year following disease onset. TRACP-5b and BAP significantly increased in RPOH type 2 compared with type 1 and OA. Receiver operating characteristic curve analyses indicated that TRACP-5b and BAP could differentiate RPOH type 2 from type 1 within 1 year following the onset. CTI showed no difference among the RPOH types 1 and 2 and OA. High serum levels of bone turnover markers may be associated with destruction of the femoral head in the early stage of RPOH.

Characterization of rapidly progressive osteoarthritis of the hip in its early stage.

This study aimed to characterize the process of disease progression in the early stage of rapidly progressive osteoarthritis of the hip (RPOH) and clarify its association with potential pathological factors of RPOH. This monocentric retrospective study included 41 female patients who met the criteria for RPOH, chondrolysis >2 mm during 12 months from the onset of hip pain based on a series of radiographs and computed tomography. This study also included 9 female patients with osteoarthritis secondary to developmental dysplasia of the hip (DDH) who demonstrated chondrolysis >2 mm during 12 months from the onset of hip pain. Cortical thickness index (CTI) correlated with bone mineral density of the hip, pelvic tilt, and serum concentrations of matrix metalloproteinase (MMP)-3 were analyzed. RPOH was classified into two types based on the absence (type 1, n=17) and presence (type 2, n=24) of subsequent femoral head destruction within 12 months after the onset of hip pain. MMP-3 significantly increased in RPOH type 2 compared with type 1 and DDH. Increased posterior pelvic tilt was found in RPOH type 2 compared with DDH. Logistic regression and receiver operating characteristic curve analyses indicated that MMP-3 may be associated with differentiation between RPOH types 1 and 2. No difference was found in the CTI between the RPOH types and DDH. Disease progression of RPOH during 12 months after the onset of hip pain could be classified into two distinct types based on the absence (type 1) and presence (type 2) of femoral head destruction in association with MMP-3 and pelvic tilt as biological and mechanical factors, respectively. MMP-3 may be helpful to differentiate these two types in the early stage of RPOH.

Is This Rapid Destructive Hip Osteoarthritis ?

Rapid destructive hip osteoarthritis is a diagnosis by exclusion. It should be differentiated from septic arthritis, osteonecrosis, neuropathic arthritis and other aetiologies causing rapid bone resorption or destruction around the hip. The present study aims to review the incidence of rapid destructive hip osteoarthritis among those patients who request total hip arthroplasty for end stage arthrosis.A retrospective review of radiographs of all patients who scheduled for total hip arthroplasty from January 2010 to March 2019 were analysed by 3 orthopaedic fellows. Of 174 hips of 146 patients, 35 hips of 29 patients were considered by at least 2 orthopaedic fellows to have rapid destructive hip osteoarthritis based on radiographic criteria of rapid joint space narrowing or rapid destruction of femoral head with or without acetabular involvement. Clinical history and physical finding, blood biochemistry, cultures and pathology with or without frozen section are reviewed.Early total hip arthroplasty, rather than routine operation in the long waiting list, is recommended for rapid destructive hip osteoarthritis to prevent technical difficulty in dealing with the bone loss or defect associated with rapid destructive hip osteoarthritis. However, one must exclude septic arthritis before proceeding to total hip arthroplasty. In clinically highly suspected cases, staged total hip arthroplasty was done despite of normal initial blood investigationsand negative hip aspiration with equivocal frozen section on table. In one such patient, the culture was initially negative, but became positive only after extended period of culture. On the other hand, rapid destruction of acetabulum requiring impaction bone grafting and acetabular augmentation for total hip arthroplasty was needed in one patient. Malignancy was suspected in another patient, but there was no evidence of malignancy or infection in the femoral head and tissue obtained by excisional arthroplasty of hip. One patient with hip pain and bilateral hip involvement was found to have Charcot joint.Rapid destruction hip osteoarthritis represents an uncommon subset of arthrosis with rapid progression. A delicate balance between correct diagnosis and timely early operation should be exercised to prevent rapid loss of bone stock making delayed total hip arthroplasty become technical difficult with possible compromised outcomes.

The mysteries of rapidly destructive arthrosis of the hip joint: a systemic literature review.

Rapidly destructive arthrosis (RDA) is considered a rare and poorly diagnosed disease but is now seen more frequently in practice due to ageing populations. The most typical radiological features are flat femoral heads, absence of articular cartilage, subchondral bone destruction and signs of joint effusion. These features could be found on X-ray or magnetic resonance imaging (MRI). Surgeons should consider the presence of RDA when patients show rapid femoral head destruction. The purpose of this study is to review the distinct clinical features and successful treatments which may lead to the diagnosis and early handling of RDA. A comprehensive review of the literature was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with no language restrictions. Overall 23 publications with 17 detailed cases of RDA met the inclusion criteria. We found that the only prevalent factors associated with RDA were: (I) age greater than 60 years; (II) female gender; (III) presence of underlying systemic diseases such as rheumatoid arthritis, diabetes mellitus or systemic lupus erythematosus. Further studies should be conducted to clarify the histopathology and define the diagnosis as well as the treatment.

Porous Se@SiO2 nanocomposites protect the femoral head from methylprednisolone-induced osteonecrosis.

BackgroundMethylprednisolone (MPS) is an important drug used in therapy of many diseases. However, osteonecrosis of the femoral head is a serious damage in the MPS treatment. Thus, it is imperative to develop new drugs to prevent the serious side effect of MPS.MethodsThe potential interferences Se@SiO2 nanocomposites may have to the therapeutic effect of methylprednisolone (MPS) were evaluated by classical therapeutic effect index of acute respiratory distress syndrome (ARDS), such as wet-to-dry weight ratio, inflammatory factors IL-1β and TNF-α. And oxidative stress species (ROS) index like superoxide dismutase (SOD) and glutathione (GSH) were tested. Then, the protection effects of Se@SiO2 have in osteonecrosis of the femoral head (ONFH) were evaluated by micro CT, histologic analysis and Western-blot analysis.ResultsIn the present study, we found that in the rat model of ARDS, Se@SiO2 nanocomposites induced SOD and GSH indirectly to reduce ROS damage. The wet-to-dry weight ratio of lung was significantly decreased after MPS treatment compared with the control group, whereas the Se@SiO2 did not affect the reduced wet-to-dry weight ratio of MPS. Se@SiO2 also did not impair the effect of MPS on the reduction of inflammatory factors IL-1β and TNF-α, and on the alleviation of structural destruction. Furthermore, micro CT and histologic analysis confirmed that Se@SiO2 significantly alleviate MPS-induced destruction of femoral head. Moreover, compared with MPS group, Se@SiO2 could increase collagen II and aggrecan, and reduce the IL-1β level in the cartilage of femoral head. In addition, the biosafety of Se@SiO2 in vitro and in vivo were supported by cell proliferation assay and histologic analysis of main organs from rat models.ConclusionSe@SiO2 nanocomposites have a protective effect in MPS-induced ONFH without influence on the therapeutic activity of MPS, suggesting the potential as effective drugs to avoid ONFH in MPS therapy.

English

Septic Arthritis also known as infectious arthritis, can be bacterial or fungal arthritis. The condition is an inflammation of a joint that is caused by an infection. Typically, Septic Arthritis affects one large joint in the body such as knee or hip. Generally, Septic Arthritis is present with complete absorption of the head of the Femur in infants. A case was encountered in which the complete absorption of the femoral head was seen in adults also. INTRODUCTION: Septic Arthritis of hip in adults is generally present with high grade fever with severe limitations of hip joint movement. The X-Ray of the Pelvis of both the hip joints in Septic Arthritis of hip in adults shows destruction of articular cartilage and narrowing of joint space and destruction of adjoining bone. But we had a case where there was a complete absorption of head of Femur with the destruction of articular surface of Acetabulum, which is more commonly seen in Septic Arthritis of hip in infants. CLINICAL HISTORY: A female patient aged about 40 years c/o high grade fever with multiple joints pain was admitted in the medical ward. The patient was investigated for all types of viral fever and other causes of fever. The patient was on IV antibiotics and analgesics with 10mg of Prednisilone twice a day. The patient c/o severe pain in the left hip joint and hence, referred to the Orthopaedic Dept. O/E, the patient was having high grade fever for the past 15 days. There was no history of injury. The patient was having multiple joint pains more on the hip joint. O/E, the hip joint was kept in 40 degrees of fixed flexion deformity with severe restriction of movements of hip joint. X-ray of pelvis with both hip joints - AP view was taken. X-ray showed that there is complete destruction of femoral head with narrowing of joint space. The patient was provisionally diagnosed as Septic Arthritis of the hip and transferred to the Orthopaedics department. INVESTIGATIONS:

Two-staged surgical treatment of hip septic arthritis

Hip arthritis (coxitis) is the inflammatory process in the hip, requiring complicated and lengthy treatment. At some cases it is associated with serious complications, up to patient’s disability due to the femoral head destruction. The treatment goal is to halt inflammation for further hip arthroplasty and functional rehabilitation. Arthroplasty is performed using the commercially available cement antibiotic-impregnated articulating spacers. The article reviews a number of clinical examples of two-staged surgical treatment of hip septic arthritis using articulating spacers with further hip arthroplasty. Experts, including native specialists, in the periodicals and clinical practice question the effectiveness of two-staged treatment. The experience of effective use of commercially available bone cement antibiotic-impregnated articulating spacers is presented. The method allows to halt the inflammation, to avoid the significant femoral shortening and acetabulum filling by scar tissue, to preserve hip function and provides the patient an opportunity to move with a partial load on the operated limb while waiting for the arthroplasty, as well as improves the conditions for hip implant consolidation. After suppressing the inflammation, the described method, providing a moderate load on the affected bone, enhances the bone mineral density increase both of femur and acetabulum. Two-staged treatment of septic coxitis decreases the risk for infective complications after the total hip replacement.

Bone morphogenetic proteins (BMPs) expression in the femoral heads of patients with avascular necrosis

Avascular necrosis (AVN) is a disorder of the bone repair process which usually results in femoral head (FH) destruction. Bone morphogenetic proteins (BMPs) are the key proteins regulating bone remodelling and healing. BMPs gene expression levels were analyzed in the normal and necrotic sites of osteonecrotic FHs. Quantitative RT-PCR for BMP-2, -4, -6, -7 genes was performed in bone tissue samples from 47 osteonecrotic FHs. Protein levels of BMP-2, -4, -6 were estimated by Western Blot. Statistical analysis was performed using the Wilcoxon signed rank test. BMP-2 and BMP-6 mRNA levels were higher in the normal than the necrotic site (normal/necrotic: 16.8/6.8 and 1.75/1.64, respectively). On the contrary, BMP-4 mRNA levels were higher in the necrotic (0.75) than the normal (0.62), while BMP-7 mRNA levels were extremely low. At the protein level, BMP-2 continued to have a higher expression in the normal region (normal/necrotic: 0.67/0.64). BMP-4 and -6 were detected at higher levels in the necrotic site (normal/necrotic: 0.51/0.61 for BMP-4, 0.51/0.56 for BMP-6), while BMP-7 was not detectable. Different BMP levels between the normal and necrotic site, as well as discrepancies between the gene and protein expression pattern suggest a different regulation mechanism for BMPs between the two regions of FHs. The understanding of the expression pattern and the correlation of BMPs could lead to a more successful use in the prevention and treatment of AVN.

Long-term follow-up of a hip joint osteoblastoma after intralesional curettage and cement packing: a case report

This article reports a case of intraarticularly expanding benign osteoblastoma of the acetabulum caused femoral head destruction by impingement in a 17-year-old male that was diagnosed for two years from the onset of symptoms. As a treatment, by surgical dislocation of the hip joint, polymethyl-methacrylate was packed inside the gap of the acetabular site after intralesional wide curettage. Femoral head remodeling was observed without recurrence after ten years follow-up.

Rapid Destruction of Femoral Head in Rheumatoid Arthritis

Rapid Destruction of Femoral Head in Rheumatoid Arthritis

Rapidly Destructive Coxarthrosis in Patients with Rheumatoid Arthritis - Report on 3 Cases -

Rapidly destructive coxarthrosis may be caused by osteoarthritis, osteonecrosis of the femoral head and rheumatoid arthritis, but its etiology has not been clarified. Rapidly destructive coxarthrosis generally occurs in old age patients and the patients clinically show severe pain, but a relatively preserved range of motion. Rapidly destructive coxarthrosis is characterized by a rapid destruction, resorption and subluxation of the femoral head, destruction of the articular area in the acetabulum, above 50% or 2 mm/year loss of the joint space and minimal osteophyte formation. The radiologic changes are dramatic and they may mimic neuropathic or septic arthritis. We report here on three cases of rheumatoid arthritis that had acute destruction of the hip joint and rapid resorption of the femoral head, and we also review the relevant medical literature. We recommend taking repetitive radiographs for rheumatoid arthritis patients who suffer with continuing severe hip pain.

Colovesical, coloenteric, colocutaneous fistula, and hip septic arthritis secondary to sigmoid diverticulitis

Dear Editor: Diverticulitis associated with free perforation and fecal or purulent peritonitis is a surgical emergency, with an associated mortality of up to 35%. Diverticular perforation into an adjacent organ can be followed by fistula formation. We report the case of a patient referred to our hospital with sigmoid diverticulitis and fecal peritonitis, which subsequently developed a complex fistula, as well as left hip septic arthritis. A 41-year-old male patient was transferred to our hospital after an acute episode of purulent sigmoid diverticulitis 2 months before; a transverse colostomy and drainage were performed. The patient was transferred due to a painful left lower extremity deformity and recurrent urinary tract infections despite antibiotic during the last 6 weeks. He showed physical signs of malnutrition, a left lower extremity flexion and adduction deformity, very limited hip motion due to pain and thigh muscular contracture, a fistulous sinus in the left lower quadrant with fecal discharge, and turbid urine through a urinary catheter. The patient denied any previous history of hip or extremity affection. Urine cultures were positive for Escherichia coli. On radiographs, a left adduction deformity and femoral head destruction suggested septic hip arthritis. The Department of Orthopedic Surgery recommended no urgent drainage since no septic state was found. A cystography showed contrast material passage to the sigmoid and left hip cavity. After a 10-day period of nutrition and systemic antibiotics, the patient was scheduled for a laparotomy. Surgical findings: a paracolic abscess and an inflammatory process affecting the sigmoid, dense adhesions to the bladder fundus, an ileum segment, iliac bone and lateral pelvis abdominal wall; fistulous communications medially from the sigmoid to the bladder and ileum 40 cm from the ileocecal valve, and laterally to the iliac bone, where the sigmoid was densely adhered to and below the inguinal ligament. Approximately 0.5 L of purulent material was drained through a communication with the hip joint cavity. An anastomosis was not considered due to the inflammatory and infectious process. Resection of the sigmoid and left colon distal to the transverse colostomy plus a Hartmann's procedure was performed. The segment of affected ileum and fistulous orifice in the bladder were resected. Ileum anastomosis and bladder repairs were practiced. Pathologic exam revealed perforated sigmoid diverticulitis, colon diverticulosis, fibrous reaction surrounding the bladder wall and ileum fistulous orifices, and absence of malignancy. After an uneventful recovery, the patient is under physical therapy. Hip replacement and bowel continuity reestablishment will be practiced. Hinchey et al. described a grading system for colonic diverticulitis. Stage I diverticulitis involves a pericolic abscess; Stage II, a distant abscess, retroperitoneal or pelvic; Stage III, purulent peritonitis; and Stage IV, fecal peritonitis. Stages III and IV are surgical emergencies, with associated mortalities of up to 35%, depending on the degree of fecal contamination, sepsis and surgical intervenNo disclaimers. There was no financial support. The paper was not presented in any meeting. It includes a list of contribution of each author/coauthor. The three authors participated in conception and design, acquisition of data, critical revision of the article, and final approval. C. M. Nuno-Guzman : J. M. Hernandez-Carlin : F. I. Almaguer Antiguo Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Calle Hospital 278, Guadalajara, Jalisco, Mexico 44280

Traumatic posterior urethral fistula to hip joint following gunshot injury: a case report

IntroductionUrinary system fistula to the hip joint is a rare complication. We report a case of delayed posterior urethral fistula to the hip joint following penetrating gunshot wound injury.Case presentationA 37-year-old Iranian Balochi male was shot with a firearm in the superior part of his right pelvis. He underwent primary closure on the same day. Ten months later, he developed urinary retention. He underwent retrograde urethrography and antegrade cystography which showed a stricture measuring 5 cm in length. There was also a history of progressive pain in the right hip joint accompanied by low grade fever which started 2 months after the initial injury. Hip X-ray showed evidence of an acetabular cavity and femoral head destruction diagnostic of complicated septic arthritis. The patient subsequently underwent reconstructive surgery for the urethral stricture and urethral fistula via a transperineal approach followed by total hip arthroplasty.ConclusionHip joint contamination with urine following a urethro-acetabular fistula can lead to severe and disabling complications such as septic arthritis. We recommend that every clinician should keep these fistulas in mind as a complication of penetrating urethral injury and every attempt should be made for their early diagnosis and prompt treatment.