Idiopathic Osteonecrosis Research Articles

The current needs of patients with idiopathic osteonecrosis of the femoral head were analyzed for the purpose of seeking effective support programs that would maintain and improve the quality of life of the patients. A focus group interview method was used to collect data. Interviewees included eight patients. They were asked about their opinions and needs with respect to medicine, health care, and welfare. Overall, four needs were revealed as particularly significant: information needs, decision-making in the absence of pre-established treatment, psychological support, and sufficient medical healthcare institutions. These four needs are useful for the foundation of future support systems, whose main concerns will be: counseling support for patients with idiopathic osteonecrosis of the femoral head, currently adopted institutions, and resources that may be required in the future.

Bilateral osteonecrosis of the tuberculum majus has not been reported in the literature. A case of bilateral avascular necrosis of the tuberculum majus is presented associated with smoking and occasional alcohol consumption as risk factors, which was successfully treated with non-operative treatment. Case report, Level V.

Legg-Calvé-Perthes disease consists of idiopathic osteonecrosis of the femoral head, causing proximal femoral growth deformity. Recent advances in surgical technique have permitted safe surgical dislocation of the hip, allowing for correction of femoracetabular impingement. The purpose of this study was to characterize the location and number of lateral epiphyseal arteries supplying the femoral head in children with healed Legg-Calvé-Perthes disease. This retrospective study included nineteen children (twenty-two hips) with a diagnosis of Legg-Calvé-Perthes disease (the LCPD group) and a matched control group of seventeen children (twenty hips) with developmental hip dysplasia. All patients underwent high-resolution contrast-enhanced magnetic resonance imaging (MRI) to visualize the path of the medial femoral circumflex artery and the lateral epiphyseal artery branches supplying the femoral head. All patients in the LCPD group were classified as having Waldenström grade-4 disease. Their average age at the time of MRI was fifteen years (range, eleven to eighteen years). The lateral epiphyseal arteries reliably inserted on the posterior-superior aspect of the femoral neck from a superior-anterior to a superior-posterior position in both groups. An average of 2.63 (standard deviation [SD], 1.47) retinacular vessels were visualized in the LCPD group, compared with 5.20 (SD, 1.06) retinacular vessels in the dysplasia group (p < 0.0001). The lateral epiphyseal arteries of the femoral head reliably insert in a narrow anatomic window on the femoral neck. Reperfusion of the medial femoral circumflex artery does occur in patients with Legg-Calvé-Perthes disease; however, the overall number of vessels is decreased as compared with that in patients with developmental hip dysplasia.

Legg-Calvé-Perthes disease is a juvenile form of idiopathic osteonecrosis of the femoral head that can lead to permanent femoral head deformity and premature osteoarthritis. According to two recent multicenter, prospective cohort studies, current nonoperative and operative treatments have modest success rates of producing a good outcome with a spherical femoral head in older children with Legg-Calvé-Perthes disease. Experimental studies have revealed that the immature femoral head is mechanically weakened following ischemic necrosis. Increased bone resorption and delayed new bone formation, in combination with continued mechanical loading of the hip, contribute to the pathogenesis of the femoral head deformity. Biological treatment strategies to improve the healing process by decreasing bone resorption and stimulating bone formation appear promising in nonhuman preclinical studies.

Treatment of Idiopathic Osteonecrosis of the Knee

Osteonecrosis is a clinical syndrome characterized by osseous necrosis of a load-bearing portion of the femoral condyle, followed by subchondral fracturing, subsequent segmental collapse and arthrosis. It most frequently affects obese women over the age of 55 years. Its treatment is still a matter of controversy in the literature. The authors report the case of a 24-year-old male patient who was a professional soccer player, who presented with a complaint of knee pain one day after physical activity. Imaging examinations performed early on already demonstrated the start of the lesion. The treatment, which was successful, used the following: withdrawal of support, physiotherapy, medications (such as NSAIDs and bisphosphonates) and a hyperbaric chamber. Although hyperbaric chamber therapy is new, its use in association with drug therapy and withdrawal of support may bring good results in treating idiopathic osteonecrosis, even for athletes with high physical demands. However, there is a need for further reports and studies with greater evidence, in order to demonstrate the validity of this treatment.

Clinical Results of Transtrochanteric Rotational Osteotomy for Idiopathic Osteonecrosis of the Femoral Head

AJR 2011; 197:W781 0361–803X/11/1974–W781 © American Roentgen Ray Society Peak Enhancement of the Femoral Head We congratulate Chan et al. [1] on their article, “Relationship of Idiopathic Osteonecrosis of the Femoral Head to Perfusion Changes in the Proximal Femur by Dynamic Contrast-Enhanced MRI.’’ In this study, they suggest that, as evaluated by dynamic contrast-enhanced MRI, intramedullary peak enhancement in the femoral head increased with progression of idiopathic osteonecrosis of the femoral head, whereas there was delayed peak enhancement in the femoral head in hips with negative findings and intertrochanteric stasis in advanced osteonecrosis of the femoral head. We find that very informative; however, we found a discrepancy between Table 1 in the article and the text in the Results section. In the text, the authors suggest that peak signal intensity was higher in the intertrochanteric area in grade 0 hips, but in the table, peak signal intensity was higher in the femoral neck. We believe that this discrepancy may result in confusion in the minds of readers. Guner Sonmez Mehmet Incedayi Ali K. Sivrioglu GATA Haydarpasa Military Hospital Istanbul, Turkey DOI:10.2214/AJR.11.6897 WEB—This is a Web exclusive article.

Langerhans cell histiocytosis (LCH), formerly called “eosinophilic granuloma,” is a benign bone neoplasm that is rare in adults. It is a cellular lesion with histiocytes, plasma cells, small lymphocytes, neutrophils, giant cells, foam cells, and eosinophilic leukocytes1. The disease typically presents during childhood, with >90% of cases occurring between the ages of five and fifteen years. LCH typically presents as a lytic medullary lesion with sharply defined margins, most commonly in the skull and in the diaphyses of long bones. The pelvis is affected in 5% to 17% of reported cases2,3. We report an unusual case of LCH presenting in the femur of a healthy young adult man following primary total hip arthroplasty for presumed idiopathic osteonecrosis. Inspection of the joint at the time of the initial surgery demonstrated no findings that were thought to warrant formal histological investigation of bone at the arthroplasty site. One year later, repeat radiographs demonstrated changes mimicking a periprosthetic infection. The prosthesis was removed, and histological examination of tissue curetted from the lytic lesions adjacent to the prosthetic femoral stem demonstrated findings consistent with a diagnosis of LCH. Cultures of curetted tissue from the same site revealed no bacterial, mycobacterial, or fungal growth. The patient, treated initially as if he had an infection at the site of the arthroplasty, underwent placement of an antibiotic cement spacer followed by revision total hip arthroplasty. At the most recent follow-up evaluation, there had been no recurrence of the LCH and the hip prosthesis was functioning well. In retrospect, LCH, which was present at revision, could have been present at the primary operation and could have been diagnosed if tissue specimens had been submitted for histological examination. This experience underscores the importance of maintaining a high index of suspicion for unexpected diagnoses …

This year (2010) represents 100 years since the simultaneous publications by Arthur Legg from the United States, Jacque Calve of France, and George Perthes of Germany of the disorder that is now known by the eponym of their names. It is presently recognized that this disorder represents idiopathic avascular necrosis or osteonecrosis of the capital femoral epiphysis. It has been one of the most controversial disorders during the past century. Although significant progress has been made in our understanding of the pathogenesis, natural history, classification, and treatment options, we still have minimal knowledge of the etiology or etiologies of this controversial disorder. At the suggestion of In Ho Choi, MD it was decided to dedicate the premeeting of the 2010 Annual Meeting of the Korean Pediatric Orthopaedic Society to this disorder. This meeting was co-sponsored by the International Federation of Pediatric Orthopaedic Societies. As the Scientific Chairman for International Federation of Pediatric Orthopaedic Societies, I cochaired this meeting with Dr Choi. It was our goal to assemble as many of the world leaders on Legg-Calve-Perthes Disease (LCPD) as possible to present the current status of the various aspects of this disorder (Fig. 1). There were 22 faculty members from 3 continents. This daylong course consisted of 4 sessions covering 23 topics and 1 session for case discussion. This included etiology, pathogenesis, stages and classifications, diagnosis, imaging, natural healing, prognosis, nonoperative treatment, pharmaceutical studies, surgical treatment (transphyseal femoral head drilling, core decompression, proximal femoral varus osteotomy, Salter osteotomy, combined femoral and pelvic osteotomy, and shelf procedures), results of the LCPD Study Group, and treatment of deformed femoral heads including the noncontainable femoral heads (valgus osteotomy), distraction, femoroacetabular impingement, transtrochanteric rotational osteotomy, and femoral head resurfacing. Each lecture was not expected to provide the definitive information but only the present status. Each speaker presented information based on their opinions coupled with intensive review of the literature published between 1910 and 2010. Although we have come a long way with respect to our understanding of LCPD, we still have much to learn regarding this common and controversial disorder. We hope the information from this symposium will be of benefit to you in the management of involved children and adolescents, and perhaps stimulate your interest in participating in future research studies.FIGURE 1: Photograph of the faculty members who assembled to celebrate the centennial of Legg-Calve-Perthes Disease at the premeeting course of the fifth Triennial Congress of International Federation of Pediatric Orthopaedic Societies combined with the 2010 Annual Meeting of the Korean Pediatric Orthopaedic Society in Seoul, Korea on September 8, 2010. Front row (left to right): Carlo Milani, In Ho Choi, George H. Thompson, Seok Hyun Lee, Tony Herring, Nando DeSanctis, Ken Kuo, Denny Wenger, Alain Demeglio. Back row (left to right): Richard Bowen, Harry Kim, Young Jo Kim, Makoto Kamegaya, Toshio Fujii, Yasuhara Hakashima, Jose Herrera-Soto, David Little, Benjamin Joseph, Nuno Craveiro Lopes, Gamal Hosny, Leonel Copelivotich, Zao Li.

Necrosis of the Ungual Process of Great Toe as Cause for Long-standing Disabling Pain: A Case Report

A peroxisome proliferator‐activated receptor gamma (<i>PPARG</i>) polymorphism is associated with zoledronic acid‐related osteonecrosis of the jaw in multiple myeloma patients: analysis by DMET microarray profiling

DiVerential diagnosis of coxalgia in young patients requires that transient hip synovitis (also known as “irritable hip”) is distinguished from septic arthritis, Legg-Calve-Perthes disease (an idiopathic avascular osteonecrosis of the femoral epiphysis), slipped capital femoral epiphysis, and pyomyositis. Transient hip synovitis recurs in up to 15% of children and may aVect the same or opposite hip [1]. Juvenile idiopathic arthritis might frequently involve the hip joint, resulting in functional impairment prior to the closure of the proximal femoral capital epiphysis [2]. X-ray Wlms, ultrasonography, and magnetic resonance imaging (MRI) are the most common instrumental tools used to assess the pediatric hip, but false negative results may occur and clinical correlation is necessary. We report the case of a 12-year-old girl who presented left hip pain, Wrstly treated with paracetamol with partial success. The patient was then admitted in a Wrst hospital for the persistent symptom: clinical examination showed restricted internal and external rotation of left hip, altered gait, and mild fever. Coxo-femoral echography showed a mild nonspeciWc left hip eVusion, suggesting the diagnosis of transient synovitis, which was treated with ibuprofen for 15 days. Pain remission was total, but in the following 3 months hip pain reappeared occasionally, though it was related to patient’s obesity (weight 62 kg, BMI 34.5). Pelvis X-ray was reported as normal at this Wrst reading. A new admission in a second hospital showed these laboratory results: Hb 10.4 g/dl, white blood cell count 12,690/ mm, platelet count 339,000/mm, erythro-sedimentation rate 73, C-reactive protein 62 mg/l, lactate dehydrogenase 429 IU/l, ferritin 159 ng/dl, and alkaline phosphatase 139 IU/l. Quantiferon test was negative. Contrast-enhanced MRI of the hip revealed an unexpected large lytic lesion in the left iliac wing, destructing the internal cortical zone (Fig. 1). Histopathology of the lesion revealed a malignant round-cell tumor consistent with Ewing’s sarcoma (ES). As a result of this diagnosis, we compared the antero-posterior view of pelvis X-ray containing the tumor area (Fig. 2) with MRI scans and found that the same osteolytic lesion in the iliac bone was misdiagnosed as a meteoric bowel distention. The sharp and clearly deWned margins without motheaten lesions might have contributed to the initial wrong false negative diagnosis. ES is the second most common primary malignant bone neoplasm in children and adolescents, accounting for approximately 10% of malignant bone tumors [3]. Frequently ES is located in the pelvis, and iliac bone is frequently involved [4]. ES of the ilium mimicking sacroiliitis has been reported [5]. Clinically ES initial symptom may be confused with infectious or rheumatologic diseases, and the classic radiological presentation of an intramedullary lesion with aggressive permeative or moth-eaten bone destruction on plain radiographs may not be the rule [6]. The value of plain Wlms of this area is compromised by the anatomy of the iliac bone and by the overlying structures; F. De Maddi · P. Siani Department of Pediatrics, Cardarelli National Hospital, Via A. Cardarelli 9, 80131 Naples, Italy

The purpose of this article is to relate intramedullary perfusion of the proximal femur to severity of osteonecrosis of the femoral head by using dynamic contrast-enhanced MRI (DCE-MRI). Twelve patients (14 symptomatic hips) who underwent DCE-MRI and had subsequent core decompression of the femoral head were examined. Hips were graded for severity according to MRI findings and were assigned scores of 0 (negative findings), 1 (focal marrow abnormalities), and 2 (subchondral collapse). Thirteen asymptomatic hips acted as controls. The DCE-MRI data were analyzed by use of a pharmacokinetic two-compartment model. Compared with control hips, there was significantly greater peak enhancement in the femoral head in hips of all grades (p < 0.001) and in the femoral neck (p = 0.001) and intertrochanteric area (p = 0.001) in grade 2 hips. The time to peak was significantly delayed in the femoral head in grade 0 hips (p = 0.02) and in the intertrochanteric area in grade 2 hips (p = 0.003) compared with the controls. As evaluated by DCE-MRI, intramedullary peak enhancement in the femoral head increased with progression of idiopathic osteonecrosis of the femoral head, whereas there was delayed peak enhancement in the femoral head in hips with negative findings and intertrochanteric stasis in advanced osteonecrosis of the femoral head. Such perfusion changes as shown on MRI can occur with early osteonecrosis in the absence of other MRI abnormalities.

Background and purpose Thrombophilia represents a risk factor both for idiopathic and secondary osteonecrosis (ON). We evaluated whether clotting changes in idiopathic ON were different from corticosteroid-associated ON. As platelet-rich plasma has been proposed as an adjuvant in surgery, we also assessed whether platelet and serum growth factors were similar to those in healthy subjects.Methods 18 patients with idiopathic ON and 18 with corticosteroid-associated ON were compared with 44 controls for acquired and inherited thrombophilia. Platelet factor 4 (PF4), transforming growth factor-β1, platelet-derived growth factor-BB (PDGF-BB), and vascular endothelial growth factor were assayed in the supernatants of thrombin-activated platelets, in platelet lysates, and in serum from 14 ON patients and 10 controls.Results Idiopathic ON patients had higher plasminogen levels (median 118%) than controls (101%) (p = 0.02). Those with corticosteroid-associated ON had significantly higher D-dimer (333 ng/mL) and lower protein C levels (129%) than controls (164 ng/mL, p = 0.004; 160%, p = 0.02). The frequency of inherited thrombophilia was not different from the controls. No statistically significant differences were found between idiopathic and corticosteroid-associated ON. 20 of the 36 ON patients were smokers. (The controls were selected from smokers because nicotine favors hypercoagulability). ON patients had significantly higher serum PF4 levels (7,383 IU/mL) and PDGF-BB levels (3.1 ng/mL) than controls (4,697 IU/mL, p = 0.005; 2.2 ng/mL, p = 0.02).Interpretation Acquired hypercoagulability was common in both ON types, but the specific changes varied. The release of GF from platelets was not affected, providing a biological basis for platelet-rich plasma being used as an adjuvant in surgical treatment.

Aseptic idiopathic osteonecrosis of the femoral head is a painful disorder of the hip that can lead to collapse of the femoral head and the need for total hip replacement following joint destruction. Treatment of this disease still remains a clinical challenge. Adult human circulating CD34(+) cells have been demonstrated to contribute to vasculogenesis and osteogenesis in immunodeficient rat non-union models in vivo. We hypothesized and proved that the transplantation of CD34(+) cells could have a role for improvement of osteonecrosis by promoting vasculogenesis and osteogenesis. Vascular deprivation-induced femoral head necrosis was developed in immunodeficient rats and we then administered human G-CSF mobilized CD34(+) cells intravenously. At 4 weeks after administration, the structure of the femoral head and neck were evaluated histologically and morphometrically with haematoxylin and eosin (H&E) staining and micro-CT imaging. Microangiography was carried out for macroscopic evaluation of neovascularization, and the contribution of human cells to vasculogenesis and osteogenesis was evaluated by immunofluorescent staining with human-specific antibodies. Our treatment resulted in an obvious improvement of osteonecrosis after CD34(+) cell administration and demonstrated the differentiation potential of CD34(+) cells into endothelial cells and osteoblasts. In conclusion, this new therapeutic approach using circulating cell fraction could be a promising cell-based therapy for early-stage osteonecrosis of the hip.

Idiopathic osteonecrosis of the scaphoid (Preiser's disease) – MRI gives new insights into etiology and pathology

BackgroundOsteonecrosis of the femoral head is classified into idiopathic and secondary forms. A number of etiological factors in the development of osteonecrosis have been suggested but the biological mechanisms are still unclear. Recently, some reports suggested that the apoptosis is closely related to osteonecrosis of the femoral head. Therefore, this study examined the expression of apoptosis in osteonecrosis of the femoral head.MethodsOf the patients diagnosed preoperatively with osteonecrosis and underwent total hip replacement arthroplasty between August 2004 and July 2005, 58 patients (58 hips) were available for this study. Their diagnoses were confirmed by the postoperative pathology findings. Tissue samples of the femoral head sections were terminal deoxynucleotydyl transferase mediated dUTP nick-end labeling (TUNEL) stained using an in situ cell death detection POD kit. The number of total and TUNEL-positive osteocytes, and the average ratio of TUNEL-positive cells were calculated and analyzed according to the cause.ResultsOsteonecrosis was steroid-induced in 8 cases (13.8%), alcohol-induced in 29 cases (50%), post-traumatic in 6 cases (10.3%) and idiopathic in 15 cases (25.9%). The percentage of TUNEL-positive osteocytes was high in patients with steroid- and alcohol-induced osteonecrosis of the femoral head but low in patients with post-traumatic and idiopathic osteonecrosis. The difference in the percentage of TUNEL-positive osteocytes between these groups was significant (p < 0.05).ConclusionsApoptosis might play an important role in the pathogenesis of osteonecrosis of the femoral head induced by steroid and alcohol. These findings highlight a need for further research into the role of apoptosis in the development of osteonecrosis of the femoral head.

The Choice of Treatment for Idiopathic Osteonecrosis of Femoral Head

Idiopathic Osteonecrosis of the Femoral Condyle Occurring in Two Sisters