Progression Of Collapse Research Articles

Volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging is associated with disease severity after collapse in osteonecrosis of the femoral head.

To evaluate the relationship between the volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging (MRI) and the disease stage of osteonecrosis of the femoral head (ONFH). Sixty-three consecutive hips in 40 ONFH patients were reviewed using contrast-enhanced MRI. Ten unaffected hips in 10 patients with unilateral ONFH were used as controls. Based on the Japanese Investigation Committee system, these hips were classified according to stage and type. The volume and location of hip synovitis were semi-quantitatively measured on contrast-enhanced MRI. Clinicoradiological factors were statistically analyzed to determine the relationship with the volume of hip synovitis. The mean synovial volume was significantly larger in ONFH hips (8,020 ± 6,900mm3) than in controls (910 ± 1,320mm3; p = 0.001). The area of synovitis in the anterior portion of the hip joint was double (mean: 2.17 ± 1.77) that in the posterior portion. The volume of synovitis was small in pre-collapse-stage hips (stage 1: 680 ± 690mm3, stage 2: 1,460 ± 1,200mm3), but significantly larger in post-collapse-stage hips (stage 3A: 7,820 ± 4,490mm3, stage 3B: 13,850 ± 7,110mm3; p < 0.001). Multiple regression analysis showed that disease stage was the only factor related to hip synovitis. Our study suggests that hip synovitis in ONFH might occur after femoral head collapse and worsen with collapse progression, mainly in the anterior portion.

Results of Simple Conservative Treatment of Midfoot Charcot Arthropathy.

BackgroundTraditionally, conservative management with an offloading orthosis, such as total contact cast (TCC), has been the standard of care for midfoot Charcot arthropathy. Considering complications of TCC and surgery, we treated midfoot Charcot arthropathy without TCC in our patients. The purpose of this study was to report clinical and radiological outcomes of conservative management of midfoot Charcot arthropathy.MethodsA total of 34 patients (38 feet) who were diagnosed as having midfoot Charcot arthropathy between 2006 and 2014 were included. Patients started full weight bearing ambulation in a hard-soled shoe immediately after diagnosis. Outcomes such as progression of arch collapse, bony prominence, ulcer occurrence, limb amputation, and changes in Charcot stage were evaluated.ResultsOf 38 feet, arch collapse was observed in four while progression of bottom bump of the midfoot was observed in five feet. Foot ulcers related to bony bumps were found in two feet.ConclusionsConservative treatment without restriction of ambulation is recommended for midfoot Charcot arthropathy because it is rarely progressive, unlike hindfoot-ankle arthropathy. In some cases, simple bumpectomy can be required to prevent catastrophic infection.

Finding Critical Element in the Progressive Collapse of RC Structures Using Sensitivity Analysis

Failure of some elements in the structure can play triggering role for beginning of collapse progression. The critical element is the structural element that when it fails, leads to progressive collapse. To find the critical element of the structure, sensitivity analysis should be done. But there are not specific structural criteria for using in sensitivity analysis. In this paper following GSA, UFC 4-023-03 and ASCE guidelines, sensitivity analysis has been modified and applied to find the critical element of a major number of reinforced concrete structures. 1080 3D nonlinear pushdown analyses were done and the results showed that the place of the critical elements differs in different stories and different plan shapes of high rise structures. In the structures with high aspect ratio in height, the critical element of the whole structure is located in the story of 2/3 height of the structure. When the aspect ratio of the structure in plan increases, sensitivity of the columns in the long dimension of the structure become closer to each other.

Transtrochanteric rotational osteotomy for various hip disorders

BackgroundJoint-preserving procedures should be considered as much as possible for hip disorders in pediatric and young patients. However, in patients with extensive osteonecrosis (ON) of the femoral head combined with severe collapse and advanced secondary osteoarthritis (OA), the optimal procedure has not been elucidated. This retrospective study aimed to investigate the postoperative outcomes of 11 patients who underwent transtrochanteric rotational osteotomy (TRO) alone or with a combination treatment for various hip disorders in young patients and to evaluate the usefulness of TRO. MethodsEleven patients (11 hips) with a mean age at operation of 22 years were included. The mean follow-up duration was 9.4 years. Preoperative diagnosis was secondary OA in 6 patients (pigmented villonodular synovitis, 2; after rotational acetabular osteotomy, 1; pyogenic arthritis, 1; femoroacetabular impingement, 1; acetabular dysplasia, 1) and ON in 5 patients (slipped capital femoral epiphysis, 4; femoral neck fracture, 1). Combination treatment was performed in 2 patients with distraction arthroplasty and in 6 patients with intra-articular procedures (mosaicplasty, 1; drilling, 1; microfracture, 4; cam resection, 1). Clinical evaluation was performed by using the Merle d’Aubigne and Postel score (MDPS). Joint congruency and progression of osteoarthritic change in all cases, and progression of collapse in the ON patients were evaluated radiographically. ResultsThe mean MDPS improved from 10.3 to 14.2 in the OA patients and from 9.4 to 14.8 in the ON patients. The OA grade was maintained or improved in 10 hips (91%). Progressive collapse was prevented in all ON patients, and good remodeling was demonstrated. ConclusionEven in the highly degenerative cases, TRO enabled repair and prevention of the progression of OA. This procedure might be a useful salvage operation for treating secondary OA and ON of the hip even if the clinical condition is advanced, especially in young patients.

The effects of a functionally-graded scaffold and bone marrow-derived mononuclear cells on steroid-induced femoral head osteonecrosis

Osteonecrosis of the femoral head (ONFH) is a debilitating disease that may progress to femoral head collapse and subsequently, degenerative arthritis. Although injection of bone marrow-derived mononuclear cells (BMMCs) is often performed with core decompression (CD) in the early stage of ONFH, these treatments are not always effective in prevention of disease progression and femoral head collapse. We previously described a novel 3D printed, customized functionally-graded scaffold (FGS) that improved bone growth in the femoral head after CD in a normal healthy rabbit, by providing structural and mechanical guidance. The present study demonstrates similar results of the FGS in a rabbit steroid-induced osteonecrosis model. Furthermore, the injection of BMMCs into the CD decreased the osteonecrotic area in the femoral head. Thus, the combination of FGS and BMMC provides a new therapy modality that may improve the outcome of CD for early stage of ONFH by providing both enhanced biological and biomechanical cues to promote bone regeneration in the osteonecrotic area.

A Multidecadal Analysis of Föhn Winds over Larsen C Ice Shelf from a Combination of Observations and Modeling

The southward progression of ice shelf collapse in the Antarctic Peninsula is partially attributed to a strengthening of the circumpolar westerlies and the associated increase in föhn conditions over its eastern ice shelves. We used observations from an automatic weather station at Cabinet Inlet on the northern Larsen C ice shelf between 25 November 2014 and 31 December 2016 to describe föhn dynamics. Observed föhn frequency was compared to the latest version of the regional climate model RACMO2.3p2, run over the Antarctic Peninsula at 5.5-km horizontal resolution. A föhn identification scheme based on observed wind conditions was employed to check for model biases in föhn representation. Seasonal variation in total föhn event duration was resolved with sufficient skill. The analysis was extended to the model period (1979–2016) to obtain a multidecadal perspective of föhn occurrence over Larsen C ice shelf. Föhn occurrence at Cabinet Inlet strongly correlates with near-surface air temperature, and both are found to relate strongly to the location and strength of the Amundsen Sea Low. Furthermore, we demonstrated that föhn occurrence over Larsen C ice shelf shows high variability in space and time.

Radiological analysis of cystic lesion in osteonecrosis of the femoral head.

Cystic lesions are a common complication in osteonecrosis of the femoral head (ONFH). This study will discuss the cause of cystic lesion formation and the feature of cystic lesion distribution in ONFH. According to the feature of cystic lesion in ONFH, we will discuss the possible mechanisms of cystic lesions and their influence on collapse of the femoral head. We retrospectively gathered 102 ONFH patients (168 hips) from November in 2015 to August in 2016 on China-Japan Friendship Hospital. Three categories of patients' medical information were collected: demographic characteristics, bone cystic lesion location, and pathological finding on CT and MRI imaging (microfracture, collapse, crescent sign). On mid-coronal and mid-axial CT section, the femoral head was divided into four quadrants for locating the cystic lesion. And we classified the location relationship of cystic lesion and sclerosis rim as G1 type, G2 type, and G3 type on coronal CT section. A significant difference was found between ONFH group with cystic lesion and ONFH group without cystic lesion in terms of microfracture (P < 0.001), collapse (P < 0.001), and crescent sign (P < 0.001). Forty-four cystic lesions (70%) are located in anterior hip area and 19 cystic lesions (30%) are located in posterior hip area. There were 14, 24, and seven cystic lesions (31, 53, 16%) locating in lateral, central, and medial pillars of the femoral head. G2 type was the most common pattern of location relationship between cystic lesion and sclerosis rim. Cystic lesions are often found near sclerosis rim in ONFH. The femoral head with osteonecrosis complicating by cystic lesions is more likely to accompany microfracture, collapse, and crescent sign which indicate structural instability in the femoral head. Cystic lesion in ONFH plays an important role in aggravating the progression of femoral head collapse. The peak stress from sclerosis rim may be a main factor inducing the formation of cystic lesion in ONFH via an OA-like mechanism.

Rotational osteotomy on the base of femoral neck in treating osteonecrosis of the femoral head

Objective To report the short-term outcomes of the rotational osteotomy on the base of femoral neck in treating osteonecrosis of femoral head. Methods Ten patients (10 hips) with osteonecrosis of femoral head underwent the rotational osteotomy on the base of femoral neck between March 2014 and October 2016. There were 9 males and 1 female. The average age was 29.6 years, ranging from 18 to 42 years. There were 4 patients in right side and 6 in left side. The Association Research Circulation Osseous (ARCO) Stage was from IIB to IIIC (2 cases of IIB, 2 cases of IIC, 1 case of IIIA, 1 case of IIIB, 4 cases of IIIC). The following main procedures were involved in the treatment: surgical hip dislocation, the extension of retinacular soft-tissue flap to protect the main blood supply of the femoral head, anterior or posterior rotational (60°-90°) of femoral head after femoral neck osteotomy. We used three compress cannulated screws to fix the femoral neck osteotomy. The postoperative Harris hip scores (HHS), Western Ontario and McMaster College (WOMAC) score, pelvic A-P view and lateral hip view radiographic characteristics were analyzed to assess the short-term outcomes. Results The average follow-up duration was 16.3 months (7-36 months). No progressive femoral head collapse was observed in 6 patients at the last follow-up. The average post-operative intact ratio was 42.90%±10.07%. The HHS improved from 80.00±14.93 to 86.83±6.11 (4 cases improved, 1 case with no change and 1 case decreased slightly). The WOMAC score decreased from 16.00±14.53 to 9.00±3.85 (1 cases increased, 1 case with no change and 4 case decreased). The remaining 4 cases, however, had the progression of the femoral head collapse. The average post-operative intact ratio was 16.57%±6.57%. The HHS decreased from 77.75±14.66 to 60.75±17.54 (1 case improved slightly and 3 cases decreased). The WOMAC score increased from 12.75±5.06 to 22.50±8.81 (4 cases increased). Conclusion The rotational osteotomy on the base of femoral neck not only shifts the necrosis area away from weight-bearing region but also improves the post-operative intact ratio. Patients with ARCO stage IIB-IIIB may achieve remission of symptoms and improvement of hip function by this surgical technique. However, for patients with IIIC stage, we should conduct preoperative design to make sure whether the surgery is worth doing or not. Some patients may suffer from post-operative progression collapse of the femoral head. Key words: Femur head necrosis; Osteotomy; Follow-up studies; Orthopedic procedures

Risk factor analysis for postoperative complications requiring revision surgery after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head

BackgroundThis study investigated the risk factors for postoperative complications requiring revision surgery within 3 years after transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH).MethodsWe reviewed 127 patients (147 hips) who underwent TRO (anterior or posterior rotational osteotomy) for ONFH between January 2002 and December 2014. Two patients were lost to follow-up, and five patients with progression of femoral head collapse requiring a salvage procedure such as total hip arthroplasty within 3 years after TRO were excluded. The better hip in patients treated bilaterally was also excluded (n = 20) to avoid duplication of patient demographics, leaving 120 hips (120 patients) for the analysis. We reviewed the medical records of each patient to screen for postoperative complications that required revision surgery within 3 years after surgery, recording the patient’s age, sex, body mass index, surgical side, condition of the contralateral hip, previous alcohol intake, previous alcohol abuse, previous corticosteroid use, perioperative corticosteroid use, smoking status, preoperative stage and type of ONFH, preoperative activity level, and preoperative and final follow-up Japanese Orthopaedic Association scores. Differences between cases with and without complications were analyzed.ResultsEleven (9.2%) cases showed postoperative complications that required revision surgery. The most common complication was deep infection (n = 5), followed by nonunion of the greater trochanter (n = 3), nonunion of the intertrochanteric osteotomy site (n = 2), and femoral head fracture (n = 1). The multivariate analysis showed an independent association between previous alcohol abuse and postoperative complications (odds ratio, 13.5).ConclusionA correlation might exist between alcohol abuse and complications following a TRO procedure.

Difference of clinical course between cases with bone union and those with delayed union following osteoporotic vertebral fractures.

Delayed union following osteoporotic vertebral fracture displayed as an intravertebral cleft on plain X-rays was reported to be a factor for prolonged severe pain. However, the difference of clinical course between bone union and delayed union cases still remains unclear. The purpose of this study was to identify how OVF delayed union following conventional conservative treatment influences the clinical course with a prospective multicenter study. A total of 324 OVF patients from 25 institutes in Osaka, Japan, were included in the study. At the 6-month follow-up after initial visit to each institute, the patients were classified into bone union and delayed union groups based on plain X-ray findings. The outcome assessments included a VAS for back pain, SF-36 for quality of life (QOL), severity of bed-ridden state for activities of daily living (ADL), MMSE for cognitive functions, and degree of vertebral collapse on plain X-rays. Overall, 280 patients were included into the union group and 44 into the delayed union group. The VAS score at 6months was significantly worse in the delayed union group (p = 0.01). The scores for the SF-36 scales of physical functioning and bodily pain at 6months were significantly lower in the delayed union group (p = 0.019, p = 0.01, respectively). The percentage of nearly or completely bed-ridden patients was significantly higher in the delayed union group. The percentage of newly developed cognitive impairment was significantly higher in the delayed union group (p = 0.02). Progression of vertebral collapse during the 6-month follow-up was more pronounced in the delayed union group (p < 0.01). The present results revealed that delayed union following OVF causes prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

The significance of spinal fixation in palliative surgery for spinal metastases

The purpose of this study is to assess appropriate fixation methods for surgical spinal stabilization for spinal metastases. 191 patients who underwent spine surgery for spinal metastases are included in this study. The surgeries included 1) posterior decompression only (29), 2) posterior decompression and fixation (153), and 3) decompression and circumferential fixation (9). We evaluated and compared all cases based upon 1) use of fixation, 2) number of levels included in the fixation, 3) type of fixation, 4) use of bone graft, 5) presence of preoperative collapse of involved vertebrae, and 6) involved area of vertebrae according to Kostuik classification. Progression of vertebral collapse on radiographs or Magnetic Resonance Imaging (MRI) or occurrence of implant failure after surgery was considered a failed case. The number of failed cases was 51 (27%). The factors that were compared between the failed and successful groups were: use of fixation (p < .01), extent of fixation (one level above and one level below affected vertebrae vs. ≧ two above and two below, p < .01), presence of preoperative collapse of affected vertebrae (p < .05), and ≧ four of six columns of vertebral involvement according to Kostuik classification (p < .01). All results were statistically significant. In conclusion, when treating metastatic spinal disease with instability, it is recommended that posterior fixation with instrumentation be used and extend at least two levels above and two below the affected vertebrae. Preoperative collapse of affected vertebrae and greater involvement of the vertebrae with metastatic disease results in greater local instability.

Microstructure and mechanical properties of eutectic B2O3–UO2 ceramic composites solidified at different cooling rates

The removal of nuclear debris from damaged reactors by drilling or cutting requires an understanding of various properties of the solidified debris, such as mechanical properties (hardness, fractural features, strength, etc.) and microstructural properties like porosity, which have a significant impact on the mechanical properties. In this study, B2O3–UO2 composites were prepared by the eutectic reaction as solidified samples of mock fuel debris with a wide variety of porosities, and the porosity dependence of the mechanical properties under compression were characterized to obtain fundamental data on the complicated fuel debris. The porous eutectic B2O3–UO2 (B2O3/UO2 atomic ratio = 0.225:0.775) samples were successfully prepared by solidification of the molten phase below 2073 K, and the porosity increased as the pore network developed as the cooling rate was decreased. The nano- and microhardness as well as Young's moduli of the eutectic B2O3–UO2 samples were higher than those of UO2. However, the compressive strengths of the eutectic B2O3–UO2 samples were lower than that of UO2, and they decreased as the porosity increased. All samples showed typical brittle fracturing behavior. The low-porosity samples showed a linear elastic step up to a sudden rupture, whereas the high-porosity samples exhibited two main regimes: a linear elastic region that can be attributed to pore-edge bending or face stretching; a zigzag step that is related to the progression of pore collapse.

Prognostic analysis of different morphology of the necrotic-viable interface in osteonecrosis of the femoral head.

The purpose of this study was to investigate the collapse progression in different morphologies of the necrotic-viable interface in osteonecrosis of the femoral head (ONFH). A total of 168 patients (202 hips) with Association Research Circulation Osseous (ARCO) stage II ONFH were included. Ending with the collapse of the femoral head, all patients received conservative treatment but without surgical intervention and were followed for three to 91months. Bilateral hip-joint radiographs and magnetic resonance imaging (MRI) were examined, and the largest layer of necrosis within the coronal section of MRI images was selected together with its anteroposterior radiograph to observe the morphology of the necrotic-viable interface. The morphology was divided into four types: I, type transverse; II, type "V"; III, type zigzag; IV, type closed. The collapse rate and the time to collapse in different morphologies were assessed. A total of 120 hips collapsed in twoyears or less, 61 were type-I, 51 were type-II, and 8 were type-III. Non-collapse occurred in all 17 hips with type-IV ONFH during long-term follow-up. In 202 hips with ARCO stage-II ONFH, the collapse rate in type-I ONFH was significantly higher than that of type-II and type-III ONFH (P<0.01 for both). The time to collapse was markedly shortened. The risk of ONFH-induced collapse is influenced by the morphology of the necrotic-viable interface. Effective mechanical support for preventing the collapse of the femoral head is necessary when the morphology of the necrotic-viable interface is type transverse.

Microstructural constraints on geotechnical properties of Malan Loess: A case study from Zhaojiaan landslide in Shaanxi province, China

The microstructure of Malan Loess (a late Pleistocene loess deposit in China) dominates its macroscopic geotechnical properties. When subject to inundating or humidifying conditions, the distinct metastable structure of the Malan Loess is sensitive to collapse; thus, its geotechnical properties undergo change. The results of triaxial and uni-axial compression tests under the humidifying conditions on undisturbed loess samples demonstrate that its geotechnical properties of the top loess were dominated by metastable structure, while the basal loess were more influenced by inter-particles cementation bond. Based on analyses from scanning electron microscopy images, change of the loess pore structure can be primarily attributed to the ratio of metastable pores (>5μm). Accordingly, an end-member model is proposed to illustrate how varying in the size and distributions of very large pores (>200μm), large pores (50–200μm), medium pores (5–50μm), and small pores (<5μm) successively change the undisturbed loess microstructure. Rising groundwater level along the base of the Malan Loess weakens the inter-particles bond, and can lead to a chain reaction where progression of pore collapse results in elevated pore pressures and loss of shear strength. This mechanism is used to explain the periodic accelerated movement of the Zhaojiaan landslide complex in northern Shaanxi, China.

Osteoporotic vertebral fractures: predictive factors for conservative treatment failure. A systematic review.

To analyze clinical, radiographic and magnetic resonance findings that might predict risk of complications and conservative treatment failure of osteoporotic vertebral fractures. The authors conducted a systematic review of observational studies, collecting data on osteoporotic vertebral fracture and complications like vertebral collapse, kyphosis, pseudoarthrosis, and neurologic deficit. MeSH items such as 'spinal fracture/radiology,' 'spinal fracture/complications,' 'spinal fracture/diagnosis' were used. PRISMA statement criteria were applied, and the risk of bias was classified as low, medium, high, following the Newcastle-Ottawa Quality Assessment Scale (NOS). Eleven cohort studies, either retrospective or prospective, met the eligibility criteria and were included in the review. Major risk factors that were statistically predictive of the following complications were as follows; (1) vertebral collapse: presence of intravertebral cleft, MR T1-WI 'total type fractures' and T2-WI 'hypointense-wide-type'. (2) Pseudoarthrosis (nonunion): middle-column damage, thoracolumbar vertebrae involvement, MR T2-WI confined high-intensity pattern and diffuse low intensity pattern. (3) Kyphotic deformity: thoracolumbar fracture and superior endplate fracture. (4) Neurologic impairment: a retropulsed bony fragment occupying more than 42% of the sagittal diameter of the spinal canal and a change of more than 15° in vertebral wedge angle on lateral dynamic radiography. Shape and level of the fracture were risk factors associated with the progression of collapse, pseudoarthrosis, kyphotic deformity and neurologic impairment. MRI findings were often related to the failure of conservative treatment. If prognosis can be predicted at the early fracture stage, more aggressive treatment options, rather than conservative ones, might be considered.

Prevalence and clinical outcomes of hip fractures and subchondral insufficiency fractures of the femoral head in patients with tumour-induced osteomalacia.

Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome usually caused by phosphaturic mesenchymal tumours, leading to great distress due to bone pain and affecting quality of life (QoL). This study aimed to investigate the prevalence and clinical outcomes of hip fractures and subchondral insufficiency fractures (SIF) of the femoral head. Twelve TIO patients were treated between January 2000 and December 2016 at our hospital. All underwent surgery for the tumour causing TIO, and complete removal of the tumour was accomplished in nine of 12 cases. Plain radiographs of the hip were obtained in all cases, and magnetic resonance imaging (MRI) was obtained from 15 hips representing eight patients before tumour removal. We evaluated the prevalence of hip fractures or SIF and their clinical outcomes. Hip fractures were observed in six of 12 cases, and the total number of fractures was nine, of which five were femoral neck, two were intertrochanteric and two were subtrochanteric fractures. Conservative treatment, regardless of complete remission of TIO, was successful except in one case with impending subtrochanteric fracture. SIFs were observed in 11 of 24 hips. Seven of 11 hips with SIF showed progression after surgery for tumour resection. Hip fractures and SIF are highly prevalent in TIO patients. Surgical and medical treatment for TIO is sufficient for treating hip fractures conservatively. However, SIF tends to show progression of femoral head collapse, serving as the main cause of pain after successful TIO treatment.

Bone marrow oedema predicts bone collapse in paediatric and adolescent leukaemia patients with corticosteroid-induced osteonecrosis.

Corticosteroid treatment of paediatric leukaemia patients can lead to osteonecrosis (ON). We determined whether bone marrow oedema (BME) is an early sign of progressive ON and eventual bone collapse. In a retrospective study, two radiologists reviewed MR imaging characteristics of 47 early stage epiphyseal ON in 15 paediatric and adolescent leukaemia patients. Associations between BME on initial imaging studies and subchondral fracture, disease progression and bone collapse were assessed by Cochran-Mantel-Haenszel tests. Differences in time to progression and bone collapse between lesions with and without oedema were assessed by log rank tests. Forty-seven occurrences of ON were located in weight bearing joints, with 77% occurring in the femur. Seventeen lesions progressed to collapse, two lesions worsened without collapse, and 28 remained stable or improved. BME was significantly associated with subchondral fracture (p = 0.0014), disease progression (p = 0.0015), and bone collapse (p < 0.001), with a sensitivity and specificity of 94% and 77%, respectively, for bone collapse. Time to progression for ON with oedema was 2.7years (95% CI: 1.7-3.4); while the majority of no-oedema ON were stable (p = 0.0011). BME is an early sign of progressive ON and eventual bone collapse in paediatric and adolescent leukaemia patients. • Bone marrow oedema in corticosteroid-induced osteonecrosis predicts progression to bone collapse. • Bone marrow oedema is associated with subchondral fractures in corticosteroid-induced osteonecrosis. • Bone marrow oedema can be used to stratify patients to joint-preserving interventions. • Absence of bone marrow oedema can justify a "wait and watch" approach.

Favorable Clinical and Radiographic Results of Transtrochanteric Anterior Rotational Osteotomy for Collapsed Subchondral Insufficiency Fracture of the Femoral Head in Young Adults.

Background:Subchondral insufficiency fracture of the femoral head (SIF) occurs infrequently in young adults. As the collapsed SIF lesion is usually located at the anterior portion of the femoral head, young adults with SIF are considered to be candidates for transtrochanteric anterior rotational osteotomy, similar to patients with osteonecrosis of the femoral head (ON). In the present study, we assessed the clinical and radiographic results of anterior rotational osteotomy for the treatment of SIF as compared with ON.Methods:We retrospectively reviewed 28 consecutive patients who underwent anterior rotational osteotomy for the treatment of unilateral SIF (7 patients) or unilateral ON (21 patients). The mean duration of follow-up was 3.7 years (range, 2.0 to 6.2 years). Clinical and radiographic assessments were performed with use of the Harris hip score (HHS), sequential radiographs, and single-photon emission computed tomography/computed tomography (SPECT/CT) with 99mTc-hydroxymethylene diphosphonate performed 5 weeks after surgery.Results:The mean HHS (and standard deviation) in the SIF group improved significantly from 51.6 ± 11.7 preoperatively to 91.9 ± 7.1 at 1 year after surgery and to 96.9 ± 3.8 at the time of the latest follow-up (p = 0.0010 and 0.0002, respectively). Similarly, the mean HHS in the ON group improved significantly from 52.4 ± 13.7 preoperatively to 80.7 ± 10.0 at 1 year after surgery and to 88.2 ± 12.6 at the time of the latest follow-up (p < 0.0001 for both). The HHS was significantly higher in the SIF group than in the ON group at 1 year after surgery (p = 0.019), but there was no significant difference between the groups at the time of the latest follow-up (p = 0.10). A postoperative intact ratio (calculated as the intact area of the femoral head divided by the weight-bearing area of the acetabulum on an anteroposterior radiograph) of >80% was achieved in association with smaller femoral neck-shaft varus angles in the SIF group (10.0° ± 4.2°) as compared with the ON group (15.3° ± 8.2°). Postoperative progression of collapse at the anteriorly rotated subchondral lesion was observed in 5 patients (23.8%) in the ON group but no patients in the SIF group. SPECT/CT images showed that rate of increased tracer uptake at the collapsed lesions in the SIF group was significantly higher than that in the ON group (p < 0.0001).Conclusions:The present study suggested that the absence of progression of collapse and a sufficient postoperative intact ratio without the need for marked varus realignment may be associated with favorable results following anterior rotational osteotomy for the treatment of SIF in young adults.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of teriparatide in the treatment of nontraumatic osteonecrosis of the femoral head: a retrospective comparative study with alendronate

BackgroundCollapse of the femoral head associated with nontraumatic osteonecrosis (NOFH) is one of the most common causes of disability in young adult patients. Excessive bone resorption by osteoclast coincident with the suppression of osteogenesis are believed to be responsible for collapse progression. Alendronate that inhibits bone resorption by inducing osteoclast apoptosis has been traditionally used for treating NOFH; however, several reports documented serious complications by the use of this drug. On the other hand, teriparatide activates osteoblasts leading to an overall increase in bone volume, and is expected to reduce the progression of femoral head collapse in NOFH. Therefore, the present study was undertaken to examine pharmacological effects of teriparatide on collapse progression of NOFH and to compare these effects with alendronate.MethodsWe conducted a retrospective study in our facility for comparing the pharmacological effects of teriparatide and alendronate on 32 NOFH patients diagnosed with osteoporosis. Between 2007 and 2013, patients were treated with daily administration of 20 μg teriparatide (15 patients: 18 hips), or with 35 mg of alendronate once a week (17 patients: 22 hips). The mean period of follow-up was 18.7 months. The progression of collapse was evaluated prior to the administration and later every three months by anteroposterior radiographs. Collapse progression with > 1 mm was defined as advanced collapse, while with < 1 mm was defined as stable radiologic disease. Student’s t-test and the chi-square test was used to do compare the pharmacological effects of the two groups.ResultsTreatment with terparatide had a tendency to reduce the rate of advanced collapse as compared to that with alendronate (p = 0.105). Kaplan-Meier curves related to stable radiologic disease showed that teriparatide-treated patients had better stable states than these treated with alendronate (p = 0.08, log-rank test). Moreover, treatment with teriparatide resulted in a significant reduction in collapse progression as compared to that with alendronate, noted at the end of follow-up period (p = 0.049).ConclusionThe present study suggests that teriparatide has greater pharmacological effects than alendronate for treating NOFH and preventing the collapse of femoral head.Trial registrationThe registration number in UMIN Clinical Trial Registry is UMIN000017582. The date of registration is May 5, 2015.

Association of early physical activity time with pain, activities of daily living, and progression of vertebral body collapse in patients with vertebral compression fractures.

Physical activity can reduce pain and improve the ability to perform daily activities in patients with acute low back pain (LBP) due to various non-specific causes. The association between physical activity during the early phase of acute vertebral compression fractures (VCFs) and rehabilitation outcomes is unknown. The aim of this study was to investigate the effects of early physical activity time (EPAT) on pain following acute VCFs, recovery of the ability to perform activities of daily living (ADLs), and progression of fractured vertebral body collapse. Observational study. Inpatient clinic. Sixty-nine patients with acute VCFs being treated conservatively at Nagasaki Memorial Hospital. Physical activity was evaluated as the activity time corresponding to 1.8-8.3 metabolic equivalent activities measured by a motion-sensor during the first week after admission; it was defined as EPAT. The verbal rating scale (VRS) (0-4) at rest and during standing and walking and motor functional independence measure (mFIM) were assessed at weeks 0 (baseline), 2, and 4. Loss of vertebral height was measured in week 4. Mini-mental state examinations, trail making test part-A (TMT-A), and geriatric depression scale-15 were administered at baseline. Patients were divided into active (N.=35) and sedentary (N.=34) groups according to their median EPAT value during the first week. The completion times for TMT-A and mFIM scores at baseline as well as the relative functional gains of mFIM from baseline to week 2 or 4 were significantly associated with EPAT. VRS at rest and during standing and walking were not significantly different between the groups at week 2 and 4. Loss of vertebral height was not significantly different between the groups. EPAT in patients with acute VCF is associated with the recovery of the ability to perform ADLs. However, EPAT is associated with neither pain reduction nor progression of fractured vertebral body collapse. This observational study indicates that physical activity in the early acute phase of VCF is associated with better recovery from acute VCF and would be an important factor for short-term recovery.