Post-traumatic Osteonecrosis Research Articles

Results of the Proximal Femoral Nail-Antirotation (PFNA) in Patients with an Unstable Pertrochanteric Fracture

Purpose: This study was performed to review the results of PFNA (Proximal Femoral Nail Antirotation) for treating unstable femoral intertrochanteric fractures. Materials and Methods: Forty-seven out of 187 hips treated from September 2006 to March 2010 with PFNA for unstable femoral pertrochanteric fractures were enrolled in this study. The mean duration to radiologic bone union, the functional status and the complications were assessed. The Cleveland index, the tip apex distance, the sliding distance of the blade and the change in the neck-shaft angle were also measured. Results: The mean duration to radiologic bone union was 15.8 weeks and 66% of the patients recovered to a premorbid functional status. The average amount of blade sliding was 5.5 mm and the mean change of the neck-shaft angle was varus 4.4。 . There were 2 cases of penetration of the blade tip, 2 cases of impending penetration, one case of posttraumatic osteonecrosis of the femoral head and 2 cases of lateral wall fractures. Conclusion: PFNA would be preferable for unstable femoral intertrochanteric fractures in terms of the short operation time, the rapid ambulatory recovery and the reduced complications. Yet careful handling is required to avoid a grave complication such as head penetration.

Costo-osteochondral graft for post-traumatic osteonecrosis of the radial head in an adolescent boy

We present a case of post-traumatic osteonecrosis of the radial head in a 13-year-old boy which was treated with costo-osteochondral grafts. A satisfactory outcome was seen at a follow-up of two years and ten months. Although costo-osteochondral grafting has been used in the treatment of defects in articular cartilage, especially in the hand and the elbow, the extension of the technique to manage post-traumatic osteonecrosis of the radial head in a child has not previously been reported in the English language literature. Complete relief of pain was obtained and an improvement in the range of movement was observed. The long-term results remain uncertain.

La prothèse d’épaule en 2010 : prothèse anatomique ou prothèse inversée ? Indications et contre-indications

Three different types of shoulder arthoplasty are currently used. Anatomical total shoulder arthroplasty, composed of two implants, which replicate normal anatomy: a humeral metallic stem ended with a hemisphere, which articulates with a concave polyethylene glenoid implant. Indications are arthropathies with functional rotator cuff: osteoarthritis, inflammatory arthropathies, aseptic osteonecrosis (grade 4 and 5 of Ficat-Arlet classification) and minor post-traumatic malunions. In those indications and without complication, pain relief is achieved in more than 90% of cases and active elevation reach in average 130°. Contra-indications are non-functional rotator cuff, insufficiency of glenoid bone stock and permanent glenohumeral instability. Reversed total shoulder arthroplasty, composed of a concave humeral implant, which articulates with a hemispherical glenoid implant. It is semi-constrained and indications are mainly cuff tear arthropathy, major post-traumatic malunions and the majority of prosthetic revisions. Results are in average excellent for pain relief, good for active elevation, more variable on internal rotation and active external rotation. Reverse arthroplasty offers solutions on previously unsolved problems. Some indications are not yet validated, as inflammatory arthropathies with deficient cuff and comminuted osteoporotic fractures in elderly patients. Contra-indication is non-functional deltoid. Excepted for particular cases, follow-up is currently too short to recommend reverse arthroplasty before 70 years. Hemiarthroplasty, which is the humeral part of the total anatomical prosthesis, articulates directly with glenoid cartilage or glenoid bone. It is indicated if glenoid side is intact as in aseptic osteonecrosis stage 2 or 3 in Ficat-Arlet classification or post-traumatic osteonecrosis. Humeral head fracture, very comminuted or with an important risk of necrosis, may be treated with a special hemiarthroplasty characterized by a large window, which helps for fixation and healing of tuberosities around the stem: this major goal is not always achieved, explaining very variable results in this indication. Hemiarthroplasty may be also a solution if conversely, glenoid bone stock is not sufficient to accept an implant, as in end stages of rheumatoid arthritis or end stage of cuff tear arthropathy: the goal is here only for pain relief.

Kummell’s disease: delayed post-traumatic osteonecrosis of the vertebral body

Delayed post-traumatic osteonecrosis, also known by its eponym Kummell's disease, is a rarely reported clinical entity that likely occurs with higher frequency than recognized. We highlight a case of a 75-year-old female household ambulator who presented with significant thoracolumbar pain and delayed T12 collapse after a ground-level fall. The patient had sustained a trivial fall at home 4 months prior to this presentation and had been hospitalized in our institution at that time for a general medical workup. Dedicated spine radiographs were not obtained during this visit. However, lateral chest radiograph demonstrated an intact T12 vertebral body. The patient was able to mobilize successfully with therapy and was discharged home. During the interim between the initial fall and subsequent presentation, she resumed physical activity including ambulating independently and performing various housework. Approximately 4 months following her initial injury, the patient returned to a local emergency department with vague complaints of abdominal pain without any history of recent fall or injury. After an unremarkable workup, the patient was sent home. Ten days later, she represented to our institution's emergency room with worsening pain. Radiographs and CT scan demonstrated interval collapse of the T12 vertebral body. A linear vacuum cleft was noted on X-rays and CT. An extensive workup to exclude other processes such as malignancy or infection, which was negative, ensued. Delayed post-traumatic vertebral collapse was diagnosed. A trial of medical management and therapy was attempted, but she continued to experience significant pain. A T12 vertebroplasty was therefore offered and performed to stabilize the injury and to relieve the pain. She was subsequently able to be discharged from the hospital and transitioned back to home life. At approximately 2 years following her injury, the patient was noted to be able to ambulate with a walking aid. Her final radiograph after her surgery demonstrated that the T12 vertebroplasty had maintained its height and sagittal alignment. This Grand Round case highlights the clinical presentation of Kummell's disease. Aspects of the clinical entity that will be discussed include a historical review of the disease, hallmark radiographic findings and treatment options.

Expert’s comment concerning Grand Rounds case entitled “Kümmell’s disease: delayed post-traumatic osteonecrosis of the vertebral body” (by R. Ma, R. Chow, F. H. Shen)

Expert’s comment concerning Grand Rounds case entitled “Kümmell’s disease: delayed post-traumatic osteonecrosis of the vertebral body” (by R. Ma, R. Chow, F. H. Shen)

Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head

The purpose of this study was to review the outcome of patients with osteonecrosis of the humeral head, based on etiology and treatment with either hemiarthroplasty or total shoulder arthroplasty (TSA). Sixty-four shoulders, with an average age of 57 years, were evaluated at a mean of 4.8 years. Outcomes included L'Insalata and American Shoulder and Elbow Surgeons (ASES) scores, as well as range of motion (ROM). The overall ASES score was 67, average flexion was 127 degrees, and external rotation was 49 degrees. Outcomes did not differ based on etiology, but ROM was decreased with post-traumatic osteonecrosis. There was no difference in outcome or ROM between hemiarthroplasty and TSA. The complication rate was significantly higher with TSA (22%) than with hemiarthroplasty (8%). Achieving ROM in patients with post-traumatic osteonecrosis remains difficult. TSA was associated with a higher complication rate and decreased mobility and should be reserved for patients with stage V osteonecrosis.

Supracondylar Correction Osteotomy to Prevent Repetitive Posterior Dislocation of a Hip Prosthesis

Recurrent dislocation of a total hip prosthesis can be a challenging and often disappointing problem. This case report describes a 78-year-old woman who had recurrent posterior dislocations of a revision total hip replacement (THR) that occurred on flexion and internal rotation of the hip. The initial THR for posttraumatic osteonecrosis and extensive revision THA were performed through an anterolateral approach. Conservative treatment was not successful in preventing posterior re-dislocation, neither was open surgery in which offset was improved. Investigation under anesthesia by means of an image-intensifier showed that the prosthesis was easily dislocated posteriorly on flexion and internal rotation. On external rotation the hip was completely stable. Flexion-internal rotation is a rare motion which, if the patient is clearly instructed should be avoidable. The mechanism of an anterior dislocation caused by external rotation, extension and adduction is more common, especially since an anterolateral approach was used in all procedures. We describe the surgical technique of performing an supracondylar external rotating osteotomy of the femur to avoid further dislocation. Fixation was performed with a condylar plate fixation of which the proximal part is fixated above the distal point of the femur component to avoid a stress riser. Since the foot and knee of the patient are now internally rotated, the patient is forced to produce an external rotation in the hip to have a normal leg alignment, therefore preventing the internal rotation on which the dislocation occurred. In the prevention of a re-dislocation, solutions other than performing a revision of the THA can successfully solve the problem and should therefore be considered.

Post-traumatic osteonecrosis of distal tibia

Post-traumatic osteonecrosis of distal tibia

Post-traumatic osteonecrosis of the lateral tibial plafond

We report a series of patients who presented with post-traumatic osteonecrosis of the lateral tibial plafond. Nine patients were identified with evidence of osteonecrosis limited to the lateral tibial plafond. All of them were seriously impaired with a mean valgus collapse of the ankle joint of 15.3°. Seven patients had a Weber C open medial fracture-dislocation, and two had a closed Weber C fracture-dislocation. This series confirms that post-traumatic osteonerosis of the lateral tibial plafond is associated with Weber C fracture-dislocation. It evolves into a valgus deformity of the ankle due to collapse of the lateral tibial plafond. The prognosis is poor and required further reconstructive surgery in all cases.

Autologous chondrocyte implantation with bone grafting for osteochondral defect due to posttraumatic osteonecrosis of the hip—a case report

Autologous chondrocyte implantation with bone grafting for osteochondral defect due to posttraumatic osteonecrosis of the hip—a case report

Early results of cementless hip arthroplasty in the treatment of femoral head posttraumatic and atraumatic osteonecrosis

To evaluate the value of cementless hip arthroplasty in the treatment of posttraumatic and atraumatic osteonecrosis (ON) of the femoral head. The study was conducted at the Department of Orthopedics and Traumatology, Military Medical Academy, between January 1st, 1999 and December 31st, 2003. Twenty-five patients with 27 implanted endoprostheses, and the diagnosis of osteonecrosis of the femoral head, and radiographically confirmed Arlet-Ficat stage III and IV were evaluated retrospectively. The results were evaluated according to Harris Hip Score (HHS). The research included 10 patients with traumatically induced osteonecrosis and 15 patients (17 endoprothesis) with osteonecrosis of the femoral head. The mean age of the patients in the group with posttraumatic osteonecrosis of the femoral head was 41 (19-62) years, and in the group of the patients with atraumatic osteonecrosis of the femoral head it was 40.2 (21-53) years. Complications included one case with postoperative luxation, and one case with iatrogenic sciatic nerve palsy. The average Harris Hip Scores in the group of posttraumatic osteonecrosis were 31 points preoperatively and 86 points postoperatively. In the group of osteonecrosis of atraumatic etiology, the average Harris Hip Score was 28 points preoperatively, and 77 points postoperatively. Postoperative Harris Hip Scores were compared with the Student's t-test and the results showed no statistically significant difference (p = 0,125). Our study did not find any significant difference between the results of posttraumatic and atraumatic osteonecrosis of the femoral head treated with cementless endoprosthesis.

Long-Term Results of Total Hip Arthroplasty using a Cemented Muller Prosthesis

Purpose : The purpose of this study was to evaluate the long-term results of cemented Muller prostheses using a 32 mm metal femoral head. Materials and Methods : We reviewed 43 (31 patients) of 76 (55 patients) consecutive THAs, which were performed between April 1978 and September 1985. The average duration of follow-up was 148 months (range, 65-279 months). The average age at the time of index operation was 44.4 years. Preoperative diagnosis was osteonecrosis in 31 hips, posttraumatic osteonecrosis in 8 hips, osteoarthritis in 2 hips, and rheumatoid arthritis in 2 hips. We assessed cases clinically by Harris hip scores and radiographically by loosening and osteolysis, and measured polyethylene wear by the Livermore method. Kaplan-Meier analysis was used to evaluate survivability. We analyzed the relationship and the statistical difference between wear and age, weight, height, body mass index, diagnosis, polyethylene thickness, and cup inclination (Pearson correlation's analysis, Student t-test, ANOVA test). The p-value was set p/yr respectively, and a 10-year cumulative survival rate was 72% (67-80%, 95% confidence interval). Revision surgery was performed in 27 hips (63%) and the mean time from index operation to revision was 129 months. The linear and volumetric wear rates increase significantly as body mass index increased (p or > ) (p

Long-term osseous sequelae after acute trauma of the knee joint evaluated by MRI

To evaluate the frequency and location and to determine the long-term MR changes in patients with edema-like bone marrow abnormalities after acute knee trauma. A cohort of 176 consecutive patients in a 29 month period with acute injury of the knee joint was examined with MRI. Forty-nine patients with bone marrow edema-like signal alteration on the initial MR examination were re-evaluated with MRI after a minimum of 2 years (mean 44 months). Signal alterations and contour abnormalities on the initial and follow-up MR examinations were classified. The volume of the edema was also measured. There was a prevalence of post-traumatic edema-like signal changes of 72% in 176 patients. In the follow-up group (n=49) the initial MR examination showed 80 areas of signal change with a mean volume of 15.5 cm3 (range 0.25-175 cm3). Thirty-five (44%) were signal changes without other bony or cartilaginous injuries, 19 (24%) were subchondral impaction fractures and 26 (33%) were osteochondral or chondral fractures. Sixty-nine percent of the lesions were located in the lateral, and 29% in the medial joint compartment. Three percent were patellar lesions. In seven of the 49 patients (14%) eight signal changes were seen on the follow-up MR examination. Six lesions were located in the same anatomic area as on the initial MR examination, and two new lesions had developed. The volume of the bone marrow edema was smaller in all persisting lesions (mean volume 2.26 cm3, range 0.3-4.8 cm3). Deterioration of the subchondral impaction, chondral/osteochondral fracture or lesions resembling osteonecrosis were not found in any patient. The majority of acute post-traumatic marrow signal changes are found in the lateral compartment and do not show additional osseous or chondral alterations. After a minimum of 2 years acute post-traumatic bone marrow edema-like signal alterations vanish in the majority of patients. Even more severe articular surface injuries such as subchondral bone impaction or chondral/osteochondral fractures will heal without obvious osseous long-term sequelae. Post-traumatic osteonecrosis, as reported in the literature, must be a rare event after acute knee trauma.

Epidemiological risk factors for non-traumatic osteonecrosis

Certain fractures and/or dislocations of the femoral head are known to cause arterial injury and result in post-traumatic osteonecrosis. However, the more complex etiology of non-traumatic osteonecrosis is multifactorial and includes chemotherapy, radiotherapy, thermal injuries, and especially coagulopathies, which are now commonly observed in these patients. Intravascular coagulation with fibrin thrombosis begins in the capillaries and sinusoids of the intraosseous microcirculation, and residual venous thrombosis is more likely to occur if there is coexistent hypofibrinolysis. Coagulopathies are intermediary events, which are always activated by some underlying etiologic risk factor(s). Conditions capable of triggering intravascular coagulation include familial thrombophilia (resistance to activated protein C, decreased protein C, protein S, or antithrombin III, and hyperhomocystinemia), hyperlipemia and embolic lipid (alcoholism and hypercortisonism), hypersensitivity reactions (allograft organ rejection, immune complexes, and antiphospholipid antibodies), bacterial endotoxic (Shwartzman) reactions and various viral infections, proteolytic enzymes (pancreatitis), tissue factor release (inflammatory bowel disease, malignancies, neurotrauma, and pregnancy), and other thrombophilic and hypofibrinolytic disorders. Currently known risk factors for non-traumatic osteonecrosis of the femoral head are described briefly in this review article.

Osteonecrosis of the humeral head: Results of replacement

One hundred twenty-seven shoulders treated with replacement arthroplasty for osteonecrosis of the humeral head were reviewed and assessed by mailed questionnaire for results, durability, and complications. These included 71 humeral head replacements and 56 total shoulder replacements. Thirty-six shoulders were lost to follow-up because of death of the patient; an additional 3 shoulders were locking survey follow-up. Thus current follow-up was available for 88 shoulders. At an average follow-up of 8.9 years, subjective improvement was expressed for 70 (79.5%) of the shoulders and no to occasional moderate pain for 68 (77.3%). The mean American Shoulder and Elbow Surgeon score was 63, and the median was 68. Inferior results in American Shoulder and Elbow Surgeon score and range of motion were noted in post-traumatic osteonecrosis, and superior results were noted in steroid-induced osteonecrosis. Little difference was found between humeral head replacement and total shoulder replacement. The most common postoperative complication was rotator cuff tearing, found in 23 (18.1%) of 127 shoulders. This complication was more common in shoulders with a history of any surgery. The cause of osteonecrosis and previous treatment have important implications for the results of shoulder replacement for this disease.

Osteonecrosis of the humeral head: results of replacement

One hundred twenty-seven shoulders treated with replacement arthroplasty for osteonecrosis of the humeral head were reviewed and assessed by mailed questionnaire for results, durability, and complications. These included 71 humeral head replacements and 56 total shoulder replacements. Thirty-six shoulders were lost to follow-up because of death of the patient; an additional 3 shoulders were lacking survey follow-up. Thus current follow-up was available for 88 shoulders. At an average follow-up of 8.9 years, subjective improvement was expressed for 70 (79.5%) of the shoulders and no to occasional moderate pain for 68 (77.3%). The mean American Shoulder and Elbow Surgeon score was 63, and the median was 68. Inferior results in American Shoulder and Elbow Surgeon score and range of motion were noted in post-traumatic osteonecrosis, and superior results were noted in steroid-induced osteonecrosis. Little difference was found between humeral head replacement and total shoulder replacement. The most common postoperative complication was rotator cuff tearing, found in 23 (18.1 %) of 127 shoulders. This complication was more common in shoulders with a history of any surgery. The cause of osteonecrosis and previous treatment have important implications for the results of shoulder replacement for this disease.

INDICATIONS, TECHNIQUE, AND RESULTS OF SHOULDER ARTHROPLASTY IN OSTEONECROSIS

The most common causes of osteonecrosis of the humeral head are steroid use and trauma. Corticosteroids produce osteonecrosis by alterations in fat metabolism, and trauma, by injury to the anterolateral ascending artery. The need for replacement surgery is influenced by stage and extent of the disease, as well as a history of trauma. Results of replacements are superior in steroid-induced osteonecrosis compared to posttraumatic osteonecrosis.

外傷性大腿骨頭壊死症に対する骨頭回転切骨術の小経験

外傷性大腿骨頭壊死症に対する骨頭回転切骨術の小経験

Posttraumatic osteonecrosis in a swine model. Correlation of blood cell flux, MRI and histology.

We used a miniature swine femoral neck fracture model to demonstrate the effects of the fracture on blood flow, histologic appearance, MRI signal and the development of posttraumatic osteonecrosis. The fracture was created and internally fixed in the right hip of 11 swine, with the left hip serving as the control. Femoral head blood flow via Laser Doppler Flowmetry and MRI data was examined for the experimental hip preoperatively, postoperatively and at 1, 2, 4 and 8 weeks postfracture. At 8 weeks, the animals were killed and the femoral heads were evaluated. Femoral head blood flow decreased immediately postfracture and continued to diminish with time. MRI signal intensities in the femoral head at 4 and 8 weeks were significantly less when the fixation failed than when it was intact. Histologic grades (0-14 points) and bone densities were 7.6 and 49%, respectively, on the experimental side, compared to 1.6 and 56% on the control side. Histologic grading, bone density values and blood flow data had no relation to changes in MRI signal intensity.

Magnetic Resonance Imaging of the Hip After Displaced Femoral Neck Fractures

This study was designed to determine the sensitivity of magnetic resonance imaging (MRI) in the detection of ischemia or avascular necrosis after displaced intracapsular hip fractures. Magnetic resonance imaging was performed on 20 patients who had hemiarthroplasties performed for Garden IV intracapsular fractures. Sixteen patients had in vivo coronal T1-weighted spin-echo imaging from the day of injury to 60 days after fracture. After hemiarthroplasty, all 20 resected femoral heads had in vitro T1 imaging. A coronal slab was then cut from the center of the femoral head and studied histologically. The in vivo, in vitro, and histologic slides correlated well. None of the MRI images depicted areas of ischemia or avascular necrosis in patterns observed in nontraumatic necrosis. Avascular bone can be indistinguishable from normal bone in both MRI and histologic sections for a considerable amount of time after vascular insult. Magnetic resonance imaging is not a prognosticator for posttraumatic osteonecrosis in the first two weeks after fracture.