Surgical Core Decompression Research Articles

Porous composite scaffold incorporating osteogenic phytomolecule icariin for promoting skeletal regeneration in challenging osteonecrotic bone in rabbits

Steroid-associated osteonecrosis (SAON) often requires surgical core decompression (CD) in the early stage for removal of necrotic bone to facilitate repair where bone grafts are needed for filling bone defect and avoiding subsequent joint collapse. In this study, we developed a bioactive composite scaffold incorporated with icariin, a unique phytomolecule that can provide structural and mechanical support and facilitate bone regeneration to fill into bone defects after surgical CD in established SAON rabbit model. An innovative low-temperature 3D printing technology was used to fabricate the poly (lactic-co-glycolic acid)/β-calcium phosphate/icariin (PLGA/TCP/Icariin, PTI) scaffold. The cytocompatibility of the PTI scaffold was tested in vitro, and the osteogenesis properties of PTI scaffolds were assessed in vivo in the SAON rabbit models. Our results showed that the fabricated PTI scaffold had a well-designed biomimic structure that was precisely printed to provide increased mechanical support and stable icariin release from the scaffold for bone regeneration. Furthermore, our in vivo study indicated that the PTI scaffold could enhanced the mechanical properties of new bone tissues and improved angiogenesis within the implanted region in SAON rabbit model than those of PLGA/TCP (PT) scaffold. The underlying osteoblastic mechanism was investigated using MC3T3-E1 cells in vitro and revealed that icariin could facilitate MC3T3-E1 cells ingrowth into the PTI scaffold and regulate osteoblastic differentiation. The PTI scaffold exhibited superior biodegradability, biocompatibility, and osteogenic capability compared with those of PT scaffold. In summary, the PTI composite scaffold which incorporated bioactive phyto-compounds is a promising potential strategy for bone tissue engineering and regeneration in patients with challenging SAON.

Bone marrow edema syndrome of the hip

Bone marrow edema syndrome of the hip is a rare condition that presents with self-limiting functional disability disproportionate to pain and signal changes on MRI consistent with bone marrow edema. Its etiology has not been established, but the most convincing theory implicates venous outflow obstruction from the diseased segment of bone. Bone marrow edema syndrome is a diagnosis of exclusion, following comprehensive work-up to rule out similarly presenting lesions. Once a diagnosis has been made a number of treatment strategies have been proposed, all with limited evidence. Conservative management is only supportive and involves analgesia and restricted weight bearing. Medical management with bisphosphonates and iloprost yield satisfactory results with minimal adverse effects. Alternative therapies include extracorporeal shock wave and hyperbaric oxygen therapy. Surgical core decompression offers immediate pain relief and faster recovery but may only be offered for severe, refractory disease.

Phytomolecule icaritin incorporated PLGA/TCP scaffold for steroid-associated osteonecrosis: Proof-of-concept for prevention of hip joint collapse in bipedal emus and mechanistic study in quadrupedal rabbits

Steroid-associated osteonecrosis (SAON) may lead to joint collapse and subsequent joint replacement. Poly lactic-co-glycolic acid/tricalcium phosphate (P/T) scaffold providing sustained release of icaritin (a metabolite of Epimedium-derived flavonoids) was investigated as a bone defect filler after surgical core-decompression (CD) to prevent femoral head collapse in a bipedal SAON animal model using emu (a large flightless bird). The underlying mechanism on SAON was evaluated using a well-established quadrupedal rabbit model. Fifteen emus were established with SAON, and CD was performed along the femoral neck for the efficacy study. In this CD bone defect, a P/T scaffold with icaritin (P/T/I group) or without icaritin (P/T group) was implanted while no scaffold implantation was used as a control. For the mechanistic study in rabbits, the effects of icaritin and composite scaffolds on bone mesenchymal stem cells (BMSCs) recruitment, osteogenesis, and anti-adipogenesis were evaluated. Our efficacy study showed that P/T/I group had the significantly lowest incidence of femoral head collapse, better preserved cartilage and mechanical properties supported by more new bone formation within the bone tunnel. For the mechanistic study, our in vitro tests suggested that icaritin enhanced the expression of osteogenesis related genes COL1α, osteocalcin, RUNX2, and BMP-2 while inhibited adipogenesis related genes C/EBP-ß, PPAR-γ, and aP2 of rabbit BMSCs. Both P/T and P/T/I scaffolds were demonstrated to recruit BMSCs both in vitro and in vivo but a higher expression of migration related gene VCAM1 was only found in P/T/I group in vitro. In conclusion, both efficacy and mechanistic studies show the potential of a bioactive composite porous P/T scaffold incorporating icaritin to enhance bone defect repair after surgical CD and prevent femoral head collapse in a bipedal SAON emu model.

Proposal of early retreatment with iloprost in partially responsive patients with bone marrow edema syndrome: a case report

Background Avascular Necrosis (AVN) is defined as the cellular death of bone components due to an alteration of the blood supply, resulting in Edema of the Bone Marrow (BME), structural collapse and bone destruction. In advanced stages, AVN requires surgery. One emerging medical treatment for supporting osseous perfusion is the administration of iloprost.Materials and methods A 38-year-old woman presented with severe BME of the left hip (primary), persisting for 6 weeks. She was treated with iloprost iv at 2 ng/kg/min for 6 hours/day for 5 days, and after 4 weeks, the treatment was repeated at 1.5 ng/kg/min for 6 hours for 5 days because she exhibited only a partial response to the first treatment. Complete remission was obtained, documented clinically and on Magnetic Resonance Imaging (MRI). Her Harris Hip Score (HHS) increased from 29.90 to 97. No significant adverse events related to iloprost were registered. No surgical procedures were necessary.Conclusions In most cases, iloprost is administered in a single cycle of treatment over 5 days at 1-2 ng/kg/min for 6 hours/day, but no research has investigated the effectiveness of early retreatment after the first cycle results in only a partially response. Only a few studies examining small numbers of patients have evaluated iloprost in AVN/BME, preferring, in most cases, the dose of 1 ng/kg/min and obtaining clinical improvement both in BME and in AVN in times comparable to surgical core decompression. This case report demonstrates the safety and effectiveness of early repetition of the maximal dose of iloprost before BME evolves into AVN, as well as in cases initially appearing serious and requiring surgical procedures.

Proposal of early retreatment with iloprost in partially responsive patients with bone marrow edema syndrome: a case report

Summary Background Avascular Necrosis (AVN) is defined as the cellular death of bone components due to an alteration of the blood supply, resulting in Edema of the Bone Marrow (BME), structural collapse and bone destruction. In advanced stages, AVN requires surgery. One emerging medical treatment for supporting osseous perfusion is the administration of iloprost. Materials and methods A 38-year-old woman presented with severe BME of the left hip (primary), persisting for 6 weeks. She was treated with iloprost iv at 2 ng/kg/min for 6 hours/day for 5 days, and after 4 weeks, the treatment was repeated at 1.5 ng/kg/min for 6 hours for 5 days because she exhibited only a partial response to the first treatment. Complete remission was obtained, documented clinically and on Magnetic Resonance Imaging (MRI). Her Harris Hip Score (HHS) increased from 29.90 to 97. No significant adverse events related to iloprost were registered. No surgical procedures were necessary. Conclusions In most cases, iloprost is administered in a single cycle of treatment over 5 days at 1-2 ng/kg/min for 6 hours/day, but no research has investigated the effectiveness of early retreatment after the first cycle results in only a partially response. Only a few studies examining small numbers of patients have evaluated iloprost in AVN/BME, preferring, in most cases, the dose of 1 ng/kg/min and obtaining clinical improvement both in BME and in AVN in times comparable to surgical core decompression. This case report demonstrates the safety and effectiveness of early repetition of the maximal dose of iloprost before BME evolves into AVN, as well as in cases initially appearing serious and requiring surgical procedures.

Natural course of intra-articular shifting bone marrow edema syndrome of the knee

BackgroundIntra-articular shift (migration) of bone marrow edema syndrome (BMES) is a very rare disease. Only a few cases have been reported thus far. The condition may cause the clinician to suspect an aggressive disease.MethodsWe reviewed eight patients (four women and four men) with unilateral BMES located in the knee. The patients were aged 39 to 56 years (mean, 49.2 years). In all patients, bone marrow edema (BME) initially observed on magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or the adjacent bone. Seven patients were given conservative therapy, including limited weight-bearing, for a period of three weeks after the initial detection of BMES, whereas one patient underwent surgical core decompression twice.ResultsMR imaging showed complete restitution in 6 cases and a small residual edema in one case. A final control MR could not be obtained for one patient, who had no pain. A further patient had an avascular necrosis of the contralateral hip after 16 months. Improvement on MR imaging was correlated with the clinical outcome in all cases. All patients became asymptomatic after a mean period of 9 months (6–11).InterpretationIntra-articular shifting BMES is a very rare condition. As the disease is self-limiting, conservative therapy may be recommended.

The use of surgical core decompression as treatment for avascular necrosis of the second and third metatarsal heads

Freiberg's disease, a type of avascular necrosis, is an idiopathic osteochondrosis disorder affecting epiphyses of developing bones in children, particularly the second metatarsal with respect to the foot. This disorder can be caused by acute trauma and has been documented that exacerbation of it is present in patients with an elongated second metatarsal, thus, making it more vulnerable to repetitive trauma. Here we present a patient with a chief complaint of a painful mass. Radiographic and repetitive MRI findings were used to diagnose the patient with Freiberg's disease. Following the benefit time of conservative care, surgical core decompression was the surgical course of treatment. Core decompression has been routinely used to prevent structural changes in the metatarsal head and to relieve pain by decreasing the increased intraosseous pressure associated with avascular necrosis and allowing for revascularization of the necrotic area. The use of surgical core decompression with respect to the metatarsal head is relatively new; but has been routinely used for the hip and knee. Whether or not this form of surgical treatment will prevent recurrence is uncertain; further long-term studies are needed.

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

REFRACTORY HIP PAIN AFTER HIKING AND PHEASANT HUNTING

791 HISTORY: A 37 y/o previously healthy professional walleye fisherman presents to Mayo Clinic's Sports Medicine Center after developing left hip/groin pain. Symptoms began after returning from a pheasant hunting expedition during which he hiked 5-8 miles/day in tall grass. He described the pain as a dull ache at rest which increased to sharp pains upon weight-bearing. His symptoms were exacerbated by a near fall on the winter ice, with hip flexed, adducted and the knee extended. He denied radicular symptoms, back pain or previous injury. He was unable to ambulate without crutches. PHYSICAL EXAMINATION: Exam showed marked antalgic gait, positive Stinchfield and FABER's tests, negative straight leg raise bilaterally. Mildly decreased passive range of motion of the left hip with guarding. Pain elicited with hip internal/external rotation and abduction. Moderate thigh atrophy. Normal reflexes and sensory exam. Muscular strain or tear Femoral stress fracture Avascular necrosis/osteonecrosis Inflammatory or infectious arthritides Bony or soft tissue tumor Focal demineralization/osteoporosis Plain radiographs→ tiny vague lucency and decreased trabeculation left femoral head and neck, preserved joint space, no osseous erosion, or collapse. Bone Scan→ homogeneous 'target-like' uptake left femoral head/neck. MRI hip/pelvis→ small left hip joint effusion, bone marrow edema left femoral head/neck, atrophy of gluteal, iliopsoas, and quadriceps muscles. Repeat MRI at 7 months → complete interval resolution of edema and effusion. DIAGNOSIS: Transient Osteoporosis of the Hip (TOH) (aka: Regional Osteopenia; Algodystrophy; Transient Focal Demineralization.) Prolonged (1-3 months) rest/ non-weight bearing to prevent microfracture/ stress fracture. Analgesics/NSAID for pain management; not likely to alter natural course of disease. Progressive assisted ambulation, ROM exercise, hip group strengthening. Steroids, calcitonin, bisphosphonates & surgical core decompression have been shown to be effective but were not employed in this case.