Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update

Updating Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH), a condition characterized by the presence of a necrotic bone lesion in the femoral head, is caused by a disruption in the blood supply. Its occurrence is more common in young and middle-aged adults and it is the main reason for performance of total hip arthroplasty in this age group. Its incidence is increasing along with increased use of glucocorticoids for management of adjuvant therapy for treatment of leukemia as well as organ transplantation and other myelogenous diseases. Current information on etiology and pathogenesis, as well as natural history, stage system, and treatments is provided in this review. A description of the Association Research Circulation Osseous (ARCO) criteria for classification of glucocorticoids- and alcohol-associated ONFH, 2019 ARCO staging system, and 2021 ARCO classification using computed tomography for the early stages of ONFH is also provided.

The effects of prophylactic tadalafil use on VEGF expression in the rabbit model of steroid-induced femoral head avascular necrosis

OBJECTIVE

The purpose of this study was to examine the effect of prophylactic tadalafil use on a steroid-induced femoral head avascular necrosis model in terms of microscopic, imaging, and molecular biological changes.

METHODS

Twenty-four New Zealand rabbits were divided into 3 equal groups. Eight rabbits were designated as the control group and did not receive treatment. Rabbits in group 1 (G1) received 0.1 mg/kg Escherichia coli lipopolysaccharide (LPS) intravenously and 40 mg/ kg methylprednisolone sodium succinate (MP) was administered intramuscularly for 3 days consecutively. Rabbits in group 2 (G2) were given 5 mg/kg tadalafil orally for 10 consecutive days. Starting on the eighth day, 0.1 mg/kg LPS was given, and following this 40 mg/kg MP injections were administered for 3 days. All animals were sacrificed 3 weeks after the final MP injection. Magnetic resonance imaging was performed, and bilateral femora were harvested. Half of the femoral head was stored for Vascular Endothelial Growth Factor (VEGF) examination with Western blot analysis. The other half was examined microscopically for the presence of osteonecrosis.

RESULTS

In G1, 15 out of 16 hips (93%) of the 8 rabbits had osteonecrosis compared to 8 out of 12 hips (67%) of 6 rabbits in G2 (P > .05). The VEGF expression in G2 was significantly higher than in the control group and G1 (P < .05 and P < .001, respectively). There was no significant difference in VEGF expression between the control group and G1 (P > .05).

CONCLUSION

This study has shown us that femoral head osteonecrosis can be reliably induced with LPS and corticosteroid, as described in the literature. Prophylactic tadalafil use did not decrease the occurrence of osteonecrosis significantly. However, it significantly increased VEGF expression in the femoral head independent of the effects of steroids and LPS.

Efficacy of Modified Lightbulb Technique by Percutaneous Femoral Neck-Head Fenestration Combined With Compacted Artificial Bone Graft for Treating Precollapse Osteonecrosis of the Femoral Head

BACKGROUND

Whether artificial bone provides comparable outcomes to autogenous bone has not been determined for osteonecrosis of the femoral head (ONFH). This study was conducted to compare the clinical outcomes of autogenous and artificial bone grafting (demineralized bone matrix/calcium sulfate [DBM/CaS]) through a modified lightbulb technique by percutaneous femoral neck-head fenestration for treating precollapse ONFH.

METHODS

A total of 73 Association Research Circulation Osseous Stage Ⅱ ONFH patients (81 hips) who had a mean follow-up of 61 months (range, 52 to 74) were included in this retrospective study. Among them were 40 hips treated with autogenous bone and 41 hips treated with DBM/CaS grafting through the percutaneous femoral neck-head fenestration. The Harris scores, radiographic progressions, clinical success rates, and survival analyses were analyzed.

RESULTS

At final follow-up, the mean Harris score was 80 points (range, 63 to 92) in the DBM/CaS group and 76 points (range, 69 to 91) in the autogenous bone group (P = .751). The radiographic progression rate was 29.9% in the DBM/CaS group, without significant difference from the autogenous bone group, which was 37.5% (P = .43). About 73.2% of patients in the DBM/CaS group and 75% in the autologous bone group avoided a total hip arthroplasty (P = .85). Survival analysis for femoral head protection revealed similar outcomes between the 2 groups (P > .05).

CONCLUSION

Percutaneous femoral neck-head fenestration combined with artificial bone (DBM/CaS) grafting had comparable clinical outcomes to autologous bone grafting on preventing femoral head collapse and rescuing THA at a mean of 61-month follow-up for treating early ONFH.

LncRNA DGCR5-encoded polypeptide RIP aggravates SONFH by repressing nuclear localization of β-catenin in BMSCs

The differentiation fate of bone marrow mesenchymal stem cells (BMSCs) affects the progression of steroid-induced osteonecrosis of the femoral head (SONFH). We find that lncRNA DGCR5 encodes a 102-amino acid polypeptide, RIP (Rac1 inactivated peptide), which promotes the adipogenic differentiation of BMSCs and aggravates the progression of SONFH. RIP, instead of lncRNA DGCR5, binds to the N-terminal motif of RAC1, and inactivates the RAC1/PAK1 cascade, resulting in decreased Ser675 phosphorylation of β-catenin. Ultimately, the nuclear localization of β-catenin decreases, and the differentiation balance of BMSCs tilts toward the adipogenesis lineage. In the femoral head of rats, overexpression of RIP causes trabecular bone disorder and adipocyte accumulation, which can be rescued by overexpressing RAC1. This finding expands the regulatory role of lncRNAs in BMSCs and suggests RIP as a potential therapeutic target.

Efficacy and safety of traditional Chinese medicine in the treatment of osteonecrosis of the femoral head

BACKGROUND

Hip joint-preserving treatment options for osteonecrosis of the femoral head (ONFH) have been a research hotspot in recent years. The combination of Chinese and Western medicine has been used in clinical practice to treat early- and mid-stage ONFH. However, there is still a lack of high-quality evidence to verify the effectiveness and safety of this approach.

OBJECTIVE

To systematically evaluate the clinical efficacy and safety of the combination of traditional Chinese medicine (TCM) with Western medicine in the treatment of early- and mid-stage ONFH.

METHODS

Multiple electronic databases were searched to identify the randomized controlled trials (RCTs) examining the use of TCM in the treatment of ONFH. Based on the inclusion and exclusion criteria, eligible studies were selected, and the quality of the studies was evaluated using the risk of bias assessment tool recommended by the Cochrane system Evaluator manual 5.1.0. The meta-analysis of the included data was performed using Review Manager 5.4.1 software and Stata 17.0 software.

RESULTS

A total of 47 RCTs involving 3266 subjects were included in the meta-analysis. The results are observed: (1) Harris score: TCM + Western medicine versus Western medicine (SMD = 1.25, 95% Cl: 1.02 to 1.48, P < 0.00001), TCM + physiotherapy versus physiotherapy (SMD = 2.26, 95% Cl: 1.42 to 3.10, P < 0.00001), and TCM + hip preservation surgery versus hip preservation surgery (SMD = 1.28, 95% Cl: 1.03 to 1.53, P < 0.00001); (2) Visual analogue scale score: TCM + Western medicine versus Western medicine (SMD = -3.99, 95% Cl: -7.41 to -0.57, P = 0.02), TCM + physiotherapy versus physiotherapy (SMD = -0.99, 95% Cl: -1.44 to -0.54, P < 0.0001), and TCM + hip preservation surgery versus hip preservation surgery (SMD = -1.08, 95% Cl: -1.75 to -0.40, P = 0.002); (3) Imaging improvement: TCM + physiotherapy versus physiotherapy (RR = 1.42, 95% Cl: 1.15 to 1.76, P = 0.001) and TCM + hip preservation surgery versus hip preservation surgery (RR = 1.21, 95% Cl: 1.11 to 1.31, P < 0.0001); and (4) Occurrence of adverse reaction: TCM + Western medicine versus Western medicine (RR = 0.73, 95% Cl: 0.28 to 1.92, P = 0.53), TCM + physiotherapy versus physiotherapy (RR = 0.46, 95% Cl: 0.03 to 7.33, P = 0.58), and TCM + hip preservation surgery versus hip preservation surgery (RR = 1.11, 95% Cl: 0.36 to 3.45, P = 0.86).

CONCLUSION

TCM combined with Western medicine is an effective and safe approach for the treatment of ONFH. However, due to the low quality and quantity of the included studies, additional large-scale, high-quality studies are required to verify the above conclusions.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/#recordDetails , CRD42023392030.

Stem cell therapy combined with core decompression versus core decompression alone in the treatment of avascular necrosis of the femoral head: a systematic review and meta-analysis

INTRODUCTION

Accumulated clinical trials had been focused on stem cell therapy in combination of core decompression (CD) in the treatment of avascular necrosis of the femoral head (ANFH). Nonetheless, the results were inconclusive. Here, we performed a systematic review and meta-analysis of previous randomized controlled trials (RCTs) and retrospective studies to assess whether combined stem cell augmentation with CD improved the outcomes of ANFH compared with CD alone.

METHODS

The current study included 11 RCTs and 7 retrospective studies reporting the clinical outcomes of a total of 916 patients and 1257 hips. 557 and 700 hips received CD and CD plus stem cell therapy, respectively. To compare CD with CD plus stem cell therapy, we examined the clinical evaluating scores, the occurrence of the femoral head, radiologic progression and conversion to total hip arthroplasty (THA).

RESULTS

Only 10 studies reported significantly greater improvement in hip functions while combining stem cell procedure with CD. The pooled results in subgroup analysis indicated that stem cell group had a lower collapse rate on a mid-term basis (P = 0.001), when combined with mechanical support (P < 0.00001), and with extracted stem cells (P = 0.0002). Likewise, stem cell group had a lower radiographic progression rate at 2- to 5-year follow-up [P = 0.003], when combined with structural grafting (P < 0.00001), and with extracted stem cells (P = 0.004). Stem cell therapy resulted in an overall lower THA conversion rate (P < 0.0001) except that at a follow-up longer than 5 years.

CONCLUSION

Stem cell therapy combined with core decompression was more effective in preventing collapse, radiographic progression and conversion to THA. Trial Registration The current protocol has been registered in PROSPERO with the registration number: CRD42023417248.

Prognosis and risk prediction of bone impaction grafting through femoral head-neck fenestration: a retrospective cohort study

The bone impaction grafting through femoral head-neck fenestration was a favorable hip preservation procedure but without prognosis estimation. This study retrospectively reviewed 79 patients' clinical data (114 hips) with osteonecrosis of the femoral head (ONFH) who underwent this procedure from June 2009 to June 2019. By the end of June 2022, the median survival time of the hip was (74.13 ± 44.88) months, and the success rate of hip preservation was 68.42%. Lateral reserved angle (LPA) and combined reserved angle (CPA) had statistically significant differences (P < 0.001) both in univariate analysis and a multivariate logistic regression model. The multivariate logistic regression model of area under curve (AUC) area of the receiver operating characteristic (ROC) curve was 0.931(sensitivity = 95.00%, specificity = 88.40%, log-rank test: P < 0.01), and the calibration curve indicated good prediction accuracy. The ROC analysis and Cox proportional hazards regression model revealed that the cutoff point of LPA was 50.95° (sensitivity = 95.00%, specificity = 72.09%, log-rank test: P < 0.05) and the cutoff point of CPA was 90.51° (sensitivity = 90.00%, specificity = 90.70%, log-rank test: P < 0.05). A nomogram plot to predict the risk of failure (C-index = 0.873, 95% CI: 0.785 to 0.961) and nomograms for predicting the survival probability at 1, 2 or 3 years whose calibration curves showed excellent prediction accuracy were available for the clinician. Preserved angles (PAs) are valuable in the prediction of prognosis in surgical treatment. The bone impaction grafting through femoral head-neck fenestration can achieve better clinical efficacy, especially for patients with LPA >50.95° and CPA >90.51°.

The efficiency of genetically modified mesenchymal stromal cells combined with a functionally graded scaffold for bone regeneration in corticosteroid-induced osteonecrosis of the femoral head in rabbits

Core decompression (CD) with mesenchymal stromal cells (MSCs) is an effective therapy for early-stage osteonecrosis of the femoral head (ONFH). Preconditioning of MSCs, using inflammatory mediators, is widely used in immunology and various cell therapies. We developed a three-dimensional printed functionally graded scaffold (FGS), made of β-TCP and PCL, for cell delivery at a specific location. The present study examined the efficacy of CD treatments with genetically modified (GM) MSCs over-expressing PDGF-BB (PDGF-MSCs) or GM MSCs co-over-expressing IL-4 and PDGF-BB and preconditioned for three days of exposure to lipopolysaccharide and tumor necrosis factor-alpha (IL-4-PDGF-pMSCs) using the FGS for treating steroid-induced ONFH in rabbits. We compared CD without cell-therapy, with IL-4-PDGF-pMSCs alone, and with FGS loaded with PDGF-MSCs or IL-4-PDGF-pMSCs. For the area inside the CD, the bone volume in the CD alone was higher than in both FGS groups. The IL-4-PDGF-pMSCs alone and FGS + PDGF-MSCs reduced the occurrence of empty lacunae and improved osteoclastogenesis. There was no significant difference in angiogenesis among the four groups. The combined effect of GM MSCs or pMSCs and the FGS was not superior to the effect of each alone. To establish an important adjunctive therapy for CD for early ONFH in the future, it is necessary and essential to develop an FGS that delivers biologics appropriately and provides structural and mechanical support.

Does Adjunction of Autologous Osteoblastic Cells Improve the Results of Core Decompression in Early-stage Femoral Head Osteonecrosis? A Double-blind, Randomized Trial

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a disabling disease that can ultimately progress to collapse of the femoral head, often resulting in THA. Core decompression of the femoral head combined with cell therapies have shown beneficial effects in previous clinical studies in patients with early-stage (Association Research Circulation Osseous [ARCO] Stage I and II) ONFH. However, high-quality evidence confirming the efficacy of this treatment modality is still lacking.

QUESTIONS/PURPOSES

(1) Is core decompression combined with autologous osteoblastic cell transplantation superior to core decompression with placebo implantation in relieving disease-associated pain and preventing radiologic ONFH progression in patients with nontraumatic early-stage ONFH? (2) What adverse events occurred in the treatment and control groups?

METHODS

This study was a Phase III, multicenter, randomized, double-blind, controlled study conducted from 2011 to 2019 (ClinicalTrails.gov registry number: NCT01529008). Adult patients with ARCO Stage I and II ONFH were randomized (1:1) to receive either core decompression with osteoblastic cell transplantation (5 mL with 20 x 10 6 cells/mL in the study group) or core decompression with placebo (5 mL of solution without cells in the control group) implantation. Thirty percent (68 of 230) of the screened patients were eligible for inclusion in the study; of these, 94% (64 of 68) underwent a bone marrow harvest or sham procedure (extended safety set) and 79% (54 of 68) were treated (study group: 25 patients; control group: 29). Forty-nine patients were included in the efficacy analyses. Similar proportions of patients in each group completed the study at 24 months of follow-up (study group: 44% [11 of 25]; control: 41% [12 of 29]). The study and control groups were comparable in important ways; for example, in the study and control groups, most patients were men (79% [27 of 34] and 87% [26 of 30], respectively) and had ARCO Stage II ONFH (76% [19 of 25] and 83% [24 of 29], respectively); the mean age was 46 and 45 years in the study and control groups, respectively. The follow-up period was 24 months post-treatment. The primary efficacy endpoint was the composite treatment response at 24 months, comprising the clinical response (clinically important improvement in pain from baseline using the WOMAC VA3.1 pain subscale, defined as 10 mm on a 100-mm scale) and radiologic response (the absence of progression to fracture stage [≥ ARCO Stage III], as assessed by conventional radiography and MRI of the hips). Secondary efficacy endpoints included the percentages of patients achieving a composite treatment response, clinical response, and radiologic response at 12 months, and the percentage of patients undergoing THA at 24 months. We maintained a continuous reporting system for adverse events and serious adverse events related to the study treatment, bone marrow aspiration and sham procedure, or other study procedures throughout the study. A planned, unblinded interim analysis of efficacy and adverse events was completed at 12 months. The study was discontinued because our data safety monitoring board recommended terminating the study for futility based on preselected futility stopping rules: conditional power below 0.20 and p = 0.01 to detect an effect size of 10 mm on the 100-mm WOMAC VA3.1 pain subscale (improvement in pain) and the absence of progression to fracture (≥ ARCO Stage III) observed on radiologic assessment, reflecting the unlikelihood that statistically beneficial results would be reached at 24 months after the treatment.

RESULTS

There was no difference between the study and control groups in the proportion of patients who achieved a composite treatment response at 24 months (61% [14 of 23] versus 69% [18 of 26]; p = 0.54). There was no difference in the proportion of patients with a treatment response at 12 months between the study and control groups (14 of 21 versus 15 of 23; p = 0.92), clinical response (17 of 21 versus 16 of 23; p = 0.38), and radiologic response (16 of 21 versus 18 of 23; p = 0.87). With the numbers available, at 24 months, there was no difference in the proportion of patients who underwent THA between the study and control groups (24% [six of 25] versus 14% [four of 29]). There were no serious adverse events related to the study treatment, and only one serious adverse event (procedural pain in the study group) was related to bone marrow aspiration. Nonserious adverse events related to the treatment were rare in the study and control groups (4% [one of 25] versus 14% [four of 29]). Nonserious adverse events related to bone marrow or sham aspiration were reported by 15% (five of 34) of patients in the study group and 7% (two of 30) of patients in the control group.

CONCLUSION

Our study did not show any advantage of autologous osteoblastic cells to improve the results of core decompression in early-stage (precollapse) ONFH. Adverse events related to treatment were rare and generally mild in both groups, although there might have been a potential risk associated with cell expansion. Based on our findings, we do not recommend the combination of osteoblastic cells and core decompression in patients with early-stage ONFH. Further, well-designed studies should be conducted to explore whether other treatment modalities involving a biological approach could improve the overall results of core decompression.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Identification of hub genes and therapeutic drugs in osteonecrosis of the femoral head through integrated bioinformatics analysis and literature mining

Osteonecrosis of the femoral head (ONFH) is a multifactorial disease leading to severely limited function. By far, the etiology and pathogenesis of ONFH are not fully understood, and surgery is the only effective way to treat ONFH. This study aims to identify hub genes and therapeutic drugs in ONFH. Two gene expression profiles were downloaded from the gene expression omnibus database, and the hub genes and candidate drugs for ONFH were identified through integrated bioinformatics analysis and cross-validated by literature mining. A total of 159 DEGs were identified. PTGS2, LRRK2, ANXA5, IGF1R, MCL1, TIMP2, LYN, CD68, CBL, and RUNX2 were validated as 10 hub genes, which has considerable implications for future genetic research and related research fields of ONFH. Our findings indicate that 85 drugs interact with ONFH, with most drugs exhibiting a positive impact on ONFH by promoting osteogenesis and angiogenesis or inhibiting microcirculation embolism, rather than being anti-inflammatory. Our study provides novel insights into the pathogenesis, prevention, and treatment of ONFH.

[Visual and quantitative assessment of the effectiveness of non-vascularized bone grafting in osteonecrosis of the femoral head via CT-based radiomics and clinical data]

Objective

To investigate the value of CT-based radiomics and clinical data in predicting the efficacy of non-vascularized bone grafting (NVBG) in hip preservation, and to construct a visual, quantifiable, and effective method for decision-making of hip preservation.

Methods

Between June 2009 and June 2019, 153 patients (182 hips) with osteonecrosis of the femoral head (ONFH) who underwent NVBG for hip preservation were included, and the training and testing sets were divided in a 7∶3 ratio to define hip preservation success or failure according to the 3-year postoperative follow-up. The radiomic features of the region of interest in the CT images were extracted, and the radiomics-scores were calculated by the linear weighting and coefficients of the radiomic features after dimensionality reduction. The clinical predictors were screened using univariate and multivariate Cox regression analysis. The radiomics model, clinical model, and clinical-radiomics (C-R) model were constructed respectively. Their predictive performance for the efficacy of hip preservation was compared in the training and testing sets, with evaluation indexes including area under the curve, C-Index, sensitivity, specificity, and calibration curve, etc. The best model was visualised using nomogram, and its clinical utility was assessed by decision curves.

Results

At the 3-year postoperative follow-up, the cumulative survival rate of hip preservation was 70.33%. Continued exposure to risk factors postoperative and Japanese Investigation Committee (JIC) staging were clinical predictors of the efficacy of hip preservation, and 13 radiomic features derived from least absolute shrinkage and selection operator downscaling were used to calculate Rad-scores. The C-R model outperformed both the clinical and radiomics models in predicting the efficacy of hip preservation 1, 2, 3 years postoperative in both the training and testing sets ( P<0.05), with good agreement between the predicted and observed values. A nomogram constructed based on the C-R model showed that patients with lower Rad-scores, no further postoperative exposure to risk factors, and B or C1 types of JIC staging had a higher probability of femoral survival at 1, 2, 3 years postoperatively. The decision curve analysis showed that the C-R model had a higher total net benefit than both the clinical and radiomics models with a single predictor, and it could bring more net benefit to patients within a larger probability threshold.

Conclusion

The prediction model and nomogram constructed by CT-based radiomics combined with clinical data is a visual, quantifiable, and effective method for decision-making of hip preservation, which can predict the efficacy of NVBG before surgery and has a high value of clinical application.

miR-486-5p Attenuates Steroid-Induced Adipogenesis and Osteonecrosis of the Femoral Head Via TBX2/P21 Axis

Enhanced adipogenic differentiation of mesenchymal stem cells (MSCs) is considered as a major risk factor for steroid-induced osteonecrosis of the femoral head (SOFNH). The role of microRNAs during this process has sparked interest. miR-486-5p expression was down-regulated significantly in femoral head bone tissues of both SONFH patients and rat models. The purpose of this study was to reveal the role of miR-486-5p on MSCs adipogenesis and SONFH progression. The present study showed that miR-486-5p could significantly inhibit adipogenesis of 3T3-L1 cells by suppressing mitotic clonal expansion (MCE). And upregulated expression of P21, which was caused by miR-486-5p mediated TBX2 decrease, was responsible for inhibited MCE. Further, miR-486-5p was demonstrated to effectively inhibit steroid-induced fat formation in the femoral head and prevented SONFH progression in a rat model. Considering the potent effects of miR-486-5p on attenuating adipogenesis, it seems to be a promising target for the treatment of SONFH.

Biomechanical Gait Analysis in Patients with Osteonecrosis of the Femoral Head

Objectives  Although osteonecrosis of the femoral head is a prevalent condition, its effects on gait parameters have not been thoroughly studied and are not well-established in the current literature. The primary aim of the present study is to describe gait in patients with a diagnosis of osteonecrosis. Methods  This is a cross-sectional study. Nine patients diagnosed with osteonecrosis of the femoral head who were regularly followed-up at an outpatient clinic were selected for the present study and underwent gait analysis using Vicon Motion Capture Systems. Spatiotemporal data was obtained, and joint angles were calculated using an Euler angle coordinate system. Distal coordinate systems were used to calculate joint moments and force plates to obtain ground reaction forces. Results  Patients with osteonecrosis presented with slower velocity (0.54 m/s ± 0.19) and smaller cadence (83.01 steps/min ± 13.23) than healthy patients. The pelvic obliquity range of motion was of 10.12° ± 3.03 and rotation was of 18.23° ± 9.17. The mean hip flexion was of 9.48° ± 3.40. Ground reaction forces showed reduced braking and propelling forces. Joint moments were reduced for flexion and adduction (0.42 Nm/kg ± 0.2 and 0.30 Nm/kg ± 0.11, respectively) but the abduction moment was increased (0.42 Nm/kg ± 0.18). Conclusions  The present study showed that osteonecrosis of the femoral head presents compensatory gait mechanisms, with increased pelvic motion and decreased knee flexion to protect the hip joint. Decreased moments for hip flexion and adduction were also identified and muscle weakness for those groups may be correlated to the disease.

Reciprocal Effect of Environmental Stimuli to Regulate the Adipogenesis and Osteogenesis Fate Decision in Bone Marrow-Derived Mesenchymal Stem Cells (BM-MSCs)

Mesenchymal stem cells derived from bone marrow (BM-MSCs) can differentiate into adipocytes and osteoblasts. Various external stimuli, including environmental contaminants, heavy metals, dietary, and physical factors, are shown to influence the fate decision of BM-MSCs toward adipogenesis or osteogenesis. The balance of osteogenesis and adipogenesis is critical for the maintenance of bone homeostasis, and the interruption of BM-MSCs lineage commitment is associated with human health issues, such as fracture, osteoporosis, osteopenia, and osteonecrosis. This review focuses on how external stimuli shift the fate of BM-MSCs towards adipogenesis or osteogenesis. Future studies are needed to understand the impact of these external stimuli on bone health and elucidate the underlying mechanisms of BM-MSCs differentiation. This knowledge will inform efforts to prevent bone-related diseases and develop therapeutic approaches to treat bone disorders associated with various pathological conditions.

Current management of avascular necrosis of the metacarpal head: a comprehensive literature review

BACKGROUND

Avascular necrosis (AVN) of the metacarpal head is a rare disease that may lead to progressive destruction of the metacarpophalangeal joint and hand function. This study aimed to describe the epidemiology, possible risk factors, clinical presentation, diagnostic workup, and treatment of the rare condition of avascular necrosis of the metacarpal head.

METHODS

Articles were searched using the subject words "Dieterich disease","Mauclaire's disease", and "avascular necrosis of metacarpal head" in the PubMed and Scopus databases. Studies were retained for review after meeting the inclusion criteria. Those outcomes relevant to diagnose and assessing AVN of the metacarpal head and those related to curative management were extracted.

RESULTS

The literature search revealed 45 studies with 55 patients. Although the aetiology of osteonecrosis has not been clearly delineated, AVN of the metacarpal head most commonly arises from trauma but other risk factors may also be involved. Plain radiographs are often negative and therefore likely to be missed. Early-stage osteonecrosis of the metacarpal head was best assessed using MRI. Given the rarity of this condition, there is no clear consensus on the treatment.

CONCLUSIONS

Avascular necrosis of the metacarpal head should be considered in the differential diagnosis of painful metacarpophalangeal joints. An early understanding of this unusual disease will provide an optimal clinical outcome, restoring joint activity, and resolving pain. Nonoperative treatment cannot cure all patients. Surgical management is based on the patient and lesion characteristics.

Application of Biomaterials in Treating Early Osteonecrosis of the Femoral Head: Research Progress and Future Perspectives

Osteonecrosis of the femoral head (ONFH), a progressive pathological process of femoral head ischemia and osteocyte necrosis, is a refractory orthopedic disease caused by multiple etiologies and there is no complete cure at present. With the extension of ONFH duration, osteocyte apoptosis and trabecular bone loss can decrease the load-bearing capacity of the femoral head, which leads to the collapse of the articular cartilage and subchondral bone. Therefore, an urgent clinical need exists to develop effective treatment strategies of early-stage ONFH for maintaining the hip joint function and preventing femoral head collapse. In recent years, extensive attention has been paid to the application of diverse biomaterials in treating early ONFH for sustaining the normal morphology and function of the autologous femoral head, and slowing disease progression. Herein, we review the research progress of bone grafts, metallic materials, bioceramics, bioglasses and polymer materials for early ONFH treatment, and discuss the biological mechanisms of bone repair and regeneration in the femoral-head necrotic area. We propose suggestions for future research directions, from a special perspective of improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts (VAOs) generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts (BAOs) and BAO-mediated bone resorption. This review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH. STATEMENT OF SIGNIFICANCE: We believe that at least three aspects of this manuscript make it interesting to readers of the Acta Biomaterialia. First, we briefly summarize the incidence, pathogenesis, risk factors, classification criteria and treatment of early osteonecrosis of the femoral head (ONFH). Second, we review the research progress in biomaterials for early ONFH treatment and the biological mechanisms of bone repair and regeneration in femoral-head necrotic area. Third, we propose future research progress on improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts and bone resorption. We hope this review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH.

Luteolin ameliorates necroptosis in Glucocorticoid-induced osteonecrosis of the femoral head via RIPK1/RIPK3/MLKL pathway based on network pharmacology analysis

Glucocorticoid-induced osteonecrosis of the femoral head (GIONFH) is deeply relevant to damage and dysfunction of bone microvascular endothelial cells (BMECs). Recently, necroptosis, a newly programmed cell death with necrotic appearance, has garnered increasing attention. Luteolin, a flavonoid compound derived from Rhizoma Drynariae, has numerous pharmacological properties. However, the effect of Luteolin on BMECs in GIONFH through the necroptosis pathway has not been extensively investigated. Based on network pharmacology analysis, 23 genes were identified as potential targets for the therapeutic effect of Luteolin in GIONFH via the necroptosis pathway, with RIPK1, RIPK3, and MLKL being the hub genes. Immunofluorescence staining results revealed high expression of vWF and CD31 in BMECs. In vitro experiments showed that incubation with dexamethasone led to reduced proliferation, migration, angiogenesis ability, and increased necroptosis of BMECs. However, pretreatment with Luteolin attenuated this effect. Based on molecular docking analysis, Luteolin exhibited strong binding affinity with MLKL, RIPK1, and RIPK3. Western blotting was utilized to detect the expression of p-MLKL, MLKL, p-RIPK3, RIPK3, p-RIPK1, and RIPK1. Intervention with dexamethasone resulted in a significant increase in the p-RIPK1/RIPK1 ratio, but the effects of dexamethasone were effectively counteracted by Luteolin. Similar findings were observed for the p-RIPK3/RIPK3 ratio and the p-MLKL/MLKL ratio, as anticipated. Therefore, this study demonstrates that Luteolin can reduce dexamethasone-induced necroptosis in BMECs via the RIPK1/RIPK3/MLKL pathway. These findings provide new insights into the mechanisms underlying the therapeutic effects of Luteolin in GIONFH treatment. Additionally, inhibiting necroptosis could be a promising novel approach for GIONFH therapy.

Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review

BACKGROUND

Several hip preserving techniques have been described for the management of osteonecrosis of the femoral head (ONFH). This systematic review identified prognostic factors in the treatment of ONFH that are associated with treatment failure and conversion to total hip arthroplasty (THA).

MATERIAL AND METHODS

This study followed the PRISMA guidelines. The literature search was conducted in November 2021. All clinical trials comparing two or more treatments for femoral head osteonecrosis were accessed. A multivariate analysis was performed to investigate the association between baseline characteristics and the surgical outcome. A multiple linear model regression analysis through the Pearson Product-Moment Correlation Coefficient (r) was used.

RESULTS

Data from 88 articles (6112 procedures) were retrieved. Female gender was associated with increased time to THA (P = 0.03) and reduced rate of THA (P = 0.03). Longer symptom duration before treatment was associated with shorter time to failure (P = 0.03). Increased pre-treatment VAS was associated with reduced time to failure (P = 0.03) and time to THA (P = 0.04). Reduced pre-treatment hip function was associated with increased rate of THA (P = 0.02) and failure (P = 0.005). Patient age and BMI, aetiology, time from surgery to full weight bearing and the side did not show evidence of a statistically significant association with the surgical outcome.

CONCLUSION

Male gender, longer symptom duration before treatment, higher VAS scores, and lower HHS scores were negative prognostic factors after treatment for osteonecrosis of the femoral head.

Bone tissue engineering for treating osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a devastating and complicated disease with an unclear etiology. Femoral head-preserving surgeries have been devoted to delaying and hindering the collapse of the femoral head since their introduction in the last century. However, the isolated femoral head-preserving surgeries cannot prevent the natural progression of ONFH, and the combination of autogenous or allogeneic bone grafting often leads to many undesired complications. To tackle this dilemma, bone tissue engineering has been widely developed to compensate for the deficiencies of these surgeries. During the last decades, great progress has been made in ingenious bone tissue engineering for ONFH treatment. Herein, we comprehensively summarize the state-of-the-art progress made in bone tissue engineering for ONFH treatment. The definition, classification, etiology, diagnosis, and current treatments of ONFH are first described. Then, the recent progress in the development of various bone-repairing biomaterials, including bioceramics, natural polymers, synthetic polymers, and metals, for treating ONFH is presented. Thereafter, regenerative therapies for ONFH treatment are also discussed. Finally, we give some personal insights on the current challenges of these therapeutic strategies in the clinic and the future development of bone tissue engineering for ONFH treatment.

Trends in Surgical Management of Osteonecrosis of the Femoral Head: A 2010 to 2020 Nationwide Study

BACKGROUND

The incidence of osteonecrosis of the femoral head (ONFH) is estimated at more than 20,000 patients annually in the US. Our study aimed to provide a 10-year analysis: 1) evaluating total operative procedures with rates normalized to the population; 2) determining trends of arthroplasty versus joint-preserving procedures; and 3) quantifying specific operative techniques in patients <50 versus >50 years of age.

METHODS

A total of 64,739 patients who were diagnosed with ONFH and underwent hip surgery were identified from a nationwide database between 2010 and 2020. The percentage of patients managed by each operative procedure was calculated and normalized to the overall population annually. Patients were grouped into joint-preserving versus non-joint-preserving (arthroplasty) procedures, and divided by age under/over 50 years. Linear regression modeling was performed to evaluate trends/differences in procedural volume by year.

RESULTS

The number of operative procedures to treat ONFH has relatively declined from 2010 to 2020. The relative proportion of joint-preserving procedures increased (8.6% to 11.2%) during this time period. There were significantly more joint-preserving procedures in patients aged <50 years relative to >50 years (15.3% versus 2.7%, P < .001). Overall, THA was the most common procedure (57,033;88.1%) relative to hemiarthroplasty (3,875;6.0%), core decompression (2,730;4.2%), bone graft (467;0.7%), and osteotomy (257;0.4%).

CONCLUSION

Surgical management of patients who have ONFH remains predominantly arthroplasty procedures (94% overall). Our findings suggest an increase in joint-preserving procedures, particularly core decompression, in patients <50 years (15.3%). Our findings provide insight into surgical management trends for ONFH, and suggest opportunities for joint-preserving procedures.

Effects of individual shock wave therapy vs celecoxib on hip pain caused by femoral head necrosis

BACKGROUND

Celecoxib has been used to treat hip discomfort and functional difficulties associated with osteonecrosis of the femoral head (ONFH), although significant adverse reactions often follow long-term use. Extracorporeal shock wave therapy (ESWT) can delay the progression of ONFH, alleviate the pain and functional limitations it causes, and avoid the adverse effects of celecoxib.

AIM

To investigate the effects of individual ESWT, a treatment alternative to the use of celecoxib, in alleviating pain and dysfunction caused by ONFH.

METHODS

This was a randomized, controlled, double-blinded, non-inferiority trial. We examined 80 patients for eligibility in this study; 8 patients were excluded based on inclusion and exclusion criteria. A total of 72 subjects with ONFH were randomly assigned to group A (n = 36; celecoxib + alendronate + sham-placebo shock wave) or group B (n = 36; individual focused shock wave [ESWT based on magnetic resonance imaging three-dimensional (MRI-3D) reconstruction] + alendronate). The outcomes were assessed at baseline, at the end of treatment, and at an 8-wk follow-up. The primary outcome measure was treatment efficiency after 2 wk of intervention using the Harris hip score (HHS) (improvement of 10 points or more from the baseline was deemed sufficient). Secondary outcome measures were post-treatment HHS, visual analog scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.

RESULTS

After treatment, the pain treatment efficiency of group B was greater than that of group A (69% vs 51%; 95%CI: 4.56% to 40.56%), with non-inferiority thresholds of -4.56% and -10%, respectively. Furthermore, the HHS, WOMAC, and VAS scores in group B dramatically improved during the follow-up period as compared to those in group A (P < 0.001). After therapy, the VAS and WOMAC in group A were significantly improved from the 2^nd to 8^th wk (P < 0.001), although HHS was only significantly altered at the 2 wk point (P < 0.001). On the 1^st d and 2^nd wk after treatment, HHS and VAS scores were different between groups, with the difference in HHS lasting until week 4. Neither group had severe complications such as skin ulcer infection or lower limb motor-sensory disturbance.

CONCLUSION

Individual shock wave therapy (ESWT) based on MRI-3D reconstruction was not inferior to celecoxib in managing hip pain and restrictions associated with ONFH.

Relationship between the degree of subchondral collapse and articular surface irregularities in osteonecrosis of the femoral head

Articular surface irregularities are often observed in collapsed femoral heads with osteonecrosis, while the effects of the degree of collapse on the articular surface are poorly understood. We first macroscopically assessed the articular surface irregularities on 2-mm coronal slices obtained using high-resolution microcomputed tomography of 76 surgically resected femoral heads with osteonecrosis. These irregularities were observed in 68/76 femoral heads, mainly at the lateral boundary of the necrotic region. The mean degree of collapse was significantly larger for femoral heads with articular surface irregularities than for those without (p < 0.0001). Receiver operating characteristic analysis showed that the cutoff value for the degree of collapse in femoral heads with articular surface irregularities at the lateral boundary was 1.1 mm. Next, for femoral heads with <3-mm collapse (n = 28), articular surface irregularities were quantitatively assessed based on the number of automatically counted negative curvature points. Quantitative evaluation showed that the degree of collapse was positively correlated with the presence of articular surface irregularities (r = 0.95, p < 0.0001). Histological examination of articular cartilage above the necrotic region (n = 8) revealed cell necrosis in the calcified layer and abnormal cellular arrangement in the deep and middle layers. In conclusion, articular surface irregularities of the necrotic femoral head depended on the degree of collapse, and articular cartilage was already altered even in the absence of macroscopically determined gross irregularities.

Worldwide research trends on femur head necrosis (2000-2021): a bibliometrics analysis and suggestions for researchers

Background

Osteonecrosis of the femoral head (ONFH) is a common and stubborn disease. The main causes are venous stasis of the femoral head, arterial blood supply damage, bone cell and bone marrow death, and bone tissue necrosis and subsequent repair obstacles. Over the past 22 years, the number of papers on ONFH has, overall, continued to increase.

Methods

Using bibliometrics, we investigated the trends, frontiers, and hotspots of global scientific output in the past 22 years. We searched Science Citation Index Expanded (SCIE) of the Web of Science Core Collection (WoSCC) and retrieved information associated with papers and records published between 2000 and 2021. We used VOSviewer and CiteSpace to conduct bibliometric analysis and visual analysis on the overall distribution of annual output, major countries, active institutions, journals, authors, commonly cited literature, and keywords. The impact and quality of the papers were assessed using the global citation score (GCS).

Results

We retrieved a total of 2006 articles and reviews. Over the past 22 years, the number of publications (NP) increased. China ranked first in terms of NP, while the United States had the highest h-index and the highest number of citations (NC). Shanghai Jiao Tong University and International Orthopaedics were the institution and periodical, respectively. The paper written by Mont et al. in 2006 had the highest total GCS score, at 379. The top three keywords were "ischemic necrosis", "osteonecrosis", and "hip joint". Although there was a fluctuation in publications associated with ONFH, overall, the NP increased. China was the most prolific in this area, while the United States was the most influential country. The top 3 authors in terms of NP were Zhang, Motomura, and Zhao. Areas of focus in ONFH over recent years include signal pathway, genetic differentiation, glucocorticoid-induced osteogenesis, induced ischemic necrosis and osteogenesis.

Conclusions

Our bibliometrics analysis revealed the research hotspots and rapid development trends of ONFH research in the past 22 years. The most critical indicators [researchers, countries, research institutions, and journals publishing osteonecrosis of the femoral head (ONFH) research] relevant to the research hotspots in the field of ONFH research were analyzed.

Antiretroviral Therapy and Periarticular Osteonecrosis Development in Patients With HIV

INTRODUCTION

With modern antiretroviral therapy (ART), HIV has become a chronic condition. Previous studies have not definitively assessed the risk of periarticular osteonecrosis (ON) that ART poses to the HIV population.

METHODS

A retrospective case-control study using the PearlDiver database was done using International Classification of Diseases codes. Patients were selected from 2010 to 2019 with a diagnosis of periarticular ON and HIV taking ART (HIV+/ART+) and not taking ART (HIV+/ART-). The control was patients HIV- and not on ART. Subcategorization, by International Classification of Diseases codes, was used for which joint was affected-hip, knee, or shoulder-excluding patients with ON of the jaw. Chi-squared univariate analysis was used to compare incidence rates and control for age, sex, Elixhauser comorbidities, and other known risk factors for developing ON in multivariable analysis.

RESULTS

In total, 219,853 patients had HIV between 2010 and 2019. Of those patients, 123,710 (56.27%) had a history of ART (HIV+/ART+), while 96,143 (43.74%) did not (HIV+/ART-). Difference in incidence rates for HIV+/ART+ was higher in any joint (+1.7%), as well as the hip (+1.31%), knee (+0.08%), and shoulder (+0.08%). All risk factors met inclusion criteria in the multivariate analysis except coagulopathy. Multivariate analysis found that patients in the HIV+/ART+ cohort had higher odds of developing periarticular ON when compared with the HIV+/ART- cohort in any joint (odds ratios = 1.40; 95% CI, 1.38 to 1.42), hip (OR:1.41; 95% CI, 1.38-1.43), knee (OR:2.56; 95% CI, 2.39 to 2.74), and shoulder (OR:1.05; 95% CI, 1.01-1.10).

CONCLUSION

Patients with HIV taking ART have well-established morbidity and mortality benefits. However, this study found that ART is associated with a higher risk of developing periarticular ON when compared with those not taking ART. Therefore, clinicians should be hypervigilant of patients on ART and their risk of ON, especially asymptomatic patients, and focus on modifiable risk factors and early surgical correction.

LEVEL OF EVIDENCE

III.

Prevalence and risk factors of osteonecrosis of the femoral head in patients with ANCA-associated vasculitis: a multicentre cohort study

OBJECTIVE

We aimed to determine the prevalence and risk factors for osteonecrosis of the femoral head (ONFH) in a multicentre cohort of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

One hundred and eighty-six AAV patients who underwent radiographs and MRI screening of bilateral hip joints at more than 6 months after initial remission induction therapy (RIT) were retrospectively assessed for the presence of ONFH.

RESULTS

Among 186 AAV patients, 33 (18%) were diagnosed with ONFH. Among the patients with ONFH, 55% were asymptomatic and 64% had bilateral ONFH. Seventy-six per cent of ONFH joints were in precollapse stages (stage ≤2), whereas 24% of ONFH joints were in collapse stages (stage ≥3). Moreover, 56% of the precollapse stage joints were already at risk of future collapse (type ≥C-1). Even in asymptomatic ONFH patients, 39% of the precollapse stage joints were type ≥C-1. Prednisolone dose of ≥20 mg/day on day 90 of RIT was an independent risk factor for ONFH in AAV patients (OR 1.072, 95% CI 1.017 to 1.130, p=0.009). Rituximab use was a significant beneficial factor against ONFH (p=0.019), but the multivariate analysis rejected its significance (p=0.257).

CONCLUSION

Eighteen per cent of AAV patients developed ONFH, and two-thirds of the ONFH joints were already in collapse stages or at risk of future collapse. Prednisolone dose of ≥20 mg/day on day 90 of RIT was an independent risk factor for ONFH. A rapid reduction of glucocorticoids in RIT and early detection of precollapse ONFH by MRI may decrease and intervene ONFH development in AAV patients.

Analysis of the potential biological mechanisms of Danyu Gukang Pill against osteonecrosis of the femoral head based on network pharmacology

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is still a challenge for orthopedists worldwide and can lead to disability if patients are not treated effectively. Danyu Gukang Pill (DGP), a traditional Chinese medicine (TCM) formulation, is recognized to be effective against ONFH. Nevertheless, its molecular mechanisms remain to be clarified.

METHODS

The active ingredients of DGP were collected from the online databases according to oral bioavailability (OB) and drug-likeness (DL). The potential targets of DGP were retrieved from the TCMSP database, while the potential targets of ONFH were obtained from the GeneCards and NCBI databases. The functions and signaling pathways of the common targets of DGP and ONFH were enriched by GO and KEGG analyses. Subsequently, molecular docking and in vitro cell experiments were performed to further validate our findings.

RESULTS

In total, 244 active ingredients of DGP and their corresponding 317 targets were obtained, and 40 ONFH-related targets were predicted. Afterwards, 19 common targets of DGP and ONFH were obtained and used as potential targets for the treatment of ONFH. Finally, combined with network pharmacology analysis, molecular docking and in vitro cell experiments, our study first demonstrated that the treatment effect of DGP on ONFH might be closely related to the two targets, HIF1A (HIF-1α) and VEGFA, and the HIF-1 signaling pathway.

CONCLUSIONS

This study is the first to investigate the molecular mechanisms of DGP in the treatment of ONFH based on network pharmacology. The results showed that DGP might up-regulate the expression of HIF-1α and VEGFA by participating in the HIF-1 signaling pathway, thus playing an anti-ONFH role.

One in five patients require conversion to arthroplasty after non-vascularized bone grafts in patients with osteonecrosis of the femoral head: a systematic review

BACKGROUND

Non-vascularized bone grafting (NVBG) has demonstrated to treat osteonecrosis of the femoral head (ONFH). There are a number of articles updating the use of NVBG to treat the ONFH, but the percentage of patients subsequently undergoing a total hip arthroplasty (THA) is controversial.

METHODS

Several electronic databases, including PubMed, Embase, Web of Science, and Cochrane databases, were searched to find studies using NVBG to treat ONFH. The pooled rate and 95% confidence interval (CI) were used to assess the conversion rate to THA after NVBG. In addition, we performed subgroup, sensitivity, and publication bias analysis.

RESULTS

A total of 37 studies describing 2599 hips were included. The mean weighted follow-up time was 50.5 months and the mean age at surgery was 36.3 years. The conversion rate to THA after NVBG was 21% (95%CI: 17% to 25%), and subgroup analyzes indicated lightbulb, trapdoor and Phemister techniques incidences with THA of 15%, 19%, and 24%, respectively.

CONCLUSIONS

This study preliminarily obtained the general trend of the survival rate of NVBG patients, but these results should be interpreted cautiously. Pooled results from 2599 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 21% of patients underwent a THA following NVBG. NVBG treatment for patient with ONFH appears to defer or at least delay the need for THA.

CT and MRI findings beyond the subchondral bone in osteonecrosis of the femoral head to distinguish between ARCO stages 2 and 3A

OBJECTIVES

To determine the diagnostic values of deep changes beyond the subchondral bone in osteonecrosis of the femoral head (ONFH) to distinguish between Association Research Circulation Osseous (ARCO) stages 2 and 3A.

METHODS

This retrospective study included 124 hips with ONFH of stages 2 (n = 49; 23 females; mean age, 50.7 years) and 3A (n = 75; 20 females; mean age, 53.2 years) from May 2017 to August 2022, who underwent CT (n = 124) and MRI (n = 85). Deep changes beyond subchondral bone were analyzed on CT (bone resorption area and cystic change) and on MRI (bone marrow edema [BME] and joint effusion). Diagnostic performance and multivariate analysis were evaluated for detecting stage 3A.

RESULTS

Stage 3A showed more frequent bone resorption area (72.0% vs. 4.1%), cystic change (52.0% vs. 0.0%), BME (93.5% vs. 43.6%), and joint effusion (76.0% vs. 24.5%) than stage 2 (p < 0.001, all). Bone resorption area and cystic change showed low sensitivities (52.0~72.0%) but high specificities (96.0~100.0%), while BME and joint effusion showed high sensitivities (76.0~93.0%) but low specificities (56.0~76.0%) for stage 3A. Predictors were in the order of bone resorption area, cystic change, and joint effusion (odds ratio: 32.952, 26.281, 9.603, respectively), and combined bone resorption area and cystic change had the best predictive value (AUC, 0.900) for stage 3A.

CONCLUSIONS

Among deep changes, bone resorption area and cystic changes were highly specific and BME and joint effusion were highly sensitive for stage 3A. Combined bone resorption area and cystic change had the best predictive value for predicting ARCO stage 3A.

KEY POINTS

• The exact classification between ARCO stage 2 and 3A is essential but it is sometimes difficult to distinguish between ARCO stage 2 and 3A only by subchondral fracture, especially early post-collapse stage with preservation of femoral head contour. • The predictors of stage 3A were in the order of bone resorption area, cystic change, and joint effusion and combined bone resorption area and cystic change had the best predictive value for predicting stage 3A. • Analysis of deep changes beyond the subchondral bone may make it easier to distinguish between ARCO stage 2 and 3A.

A Deep Learning Method for Quantification of Femoral Head Necrosis Based on Routine Hip MRI for Improved Surgical Decision Making

(1) Background: To evaluate the performance of a deep learning model to automatically segment femoral head necrosis (FHN) based on a standard 2D MRI sequence compared to manual segmentations for 3D quantification of FHN. (2) Methods: Twenty-six patients (thirty hips) with avascular necrosis underwent preoperative MR arthrography including a coronal 2D PD-w sequence and a 3D T1 VIBE sequence. Manual ground truth segmentations of the necrotic and unaffected bone were then performed by an expert reader to train a self-configuring nnU-Net model. Testing of the network performance was performed using a 5-fold cross-validation and Dice coefficients were calculated. In addition, performance across the three segmentations were compared using six parameters: volume of necrosis, volume of unaffected bone, percent of necrotic bone volume, surface of necrotic bone, unaffected femoral head surface, and percent of necrotic femoral head surface area. (3) Results: Comparison between the manual 3D and manual 2D segmentations as well as 2D with the automatic model yielded significant, strong correlations (Rp > 0.9) across all six parameters of necrosis. Dice coefficients between manual- and automated 2D segmentations of necrotic- and unaffected bone were 75 ± 15% and 91 ± 5%, respectively. None of the six parameters of FHN differed between the manual and automated 2D segmentations and showed strong correlations (Rp > 0.9). Necrotic volume and surface area showed significant differences (all p < 0.05) between early and advanced ARCO grading as opposed to the modified Kerboul angle, which was comparable between both groups (p > 0.05). (4) Conclusions: Our deep learning model to automatically segment femoral necrosis based on a routine hip MRI was highly accurate. Coupled with improved quantification for volume and surface area, as opposed to 2D angles, staging and course of treatment can become better tailored to patients with varying degrees of AVN.

Hip Preservation or Total Hip Arthroplasty? A Retrospective Case-Control Study of Factors Influencing Arthroplasty Decision-Making for Patients with Osteonecrosis of the Femoral Head in China

OBJECTIVE

At present, there is no consensus or guidance on indications for osteonecrosis of the femoral head (ONFH) patients to receive hip arthroplasty (THA) treatment. This study aims to explore the factors that influence the decision-making for THA in patients with ONFH, and to provide references for clinical decision for ONFH patients to be indicated for THA or hip preservation.

METHODS

This retrospective case-control study involved data for ONFH patients from July 2016 to October 2021 from the China Osteonecrosis of the Femoral Head Database (CONFHD). The patients with ONFH, and unilateral hip affected at the first visit were divided into THA group and non-THA group according to if they had undergone THA treatment. The differences between the two groups of patients in terms of gender, age at the time of consultation, body mass index (BMI), etiology, onset side, association research circulation osseous (ARCO) stage, hip joint function, visual analog scale (VAS), etc. were analyzed. Multivariate binomial logistic regression analysis was then applied to evaluate the risk factors of ONFH patients who underwent THA during the first visit.

RESULTS

A total of 640 patients were recruited for analysis, including 209 cases from the THA group and 431 cases from the non-THA group. The results of univariate analysis showed that the two groups of patients were significantly different in the following six indicators: age (59 vs. 46, Z = -9.58, p < 0.001), duration of disease (78 vs. 17, Z = -16.14, p < 0.001), gender composition (χ²  = 8.09, p = 0.004), disease etiology (χ²  = 33.04, p < 0.001), ARCO stage (χ²  = 334.86, p < 0.001), flexion of hip joint (χ²  = 172.33, p < 0.001). However, the comparison between the two groups on VAS (Z = -0.82, p = 0.41), BMI (Z = -1.35, p = 0.18), and onset side (χ²  = 1.53, p = 0.22) did not obviously differ. The results regression analysis showed that the age at the time of consultation, duration of disease, ARCO stage, and the hip joint function affected the decision making if the patients should undergo THA. The results of receiver operating characteristic curve (ROC) analysis showed that aforementioned indicators were satisfactory in predicting whether patients with ONFH would be treated with THA. The regression model using the above four indicators as comprehensive indicators has satisfactory performance in predicting whether to perform THA, and the area under the curve (AUC) is 93.94%.

CONCLUSION

These factors such as age, duration of disease, ARCO stage, and hip flexion function should be considered comprehensively before making decisions to perform THA or not in our clinical practice.

Hip function in patients undergoing conservative treatment for osteonecrosis of the femoral head

PURPOSE

Once collapsed, osteonecrosis of the femoral head (ONFH) generally obtains collapse cessation naturally and surgical intervention can be avoided in the long term. This study aimed to investigate the process of hip function and secondary osteoarthritis changes in ONFH patients undergoing conservative treatment.

METHODS

We included 54 patients with symptomatic ONFH at the first visit with a minimum follow-up of three years with conservative treatment. Patients were divided into two groups based on collapse cessation < 3 mm (stable group) or progression to > 3 mm (progression group). Additionally, we investigated age, sex, body mass index (BMI), etiology, contralateral side hip joint, the Japanese Investigation Committee (JIC) type classification, Harris hip score (HHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), and survival rate with secondary osteoarthritis as the endpoint.

RESULTS

The stable and progression groups had 31 and 23 patients, respectively. No significant differences in age, sex, BMI, and aetiology were observed between the two groups, except for the contralateral side hip joint and JIC type classification. The HHS and JHEQ were significantly improved at the final follow-up than at the first visit in the stable group. However, there were no significant differences in HHS and JHEQ at the final follow-up than at the first visit in the progression group. The five year survival rates with secondary osteoarthritis as the endpoint were significantly higher in the stable group (100%) than in the progression group (32.5%).

CONCLUSION

Hip joint function improved by continuing conservative treatment in ONFH patients with collapse cessation < 3 mm.

Comparison of current treatment strategy for osteonecrosis of the femoral head from the perspective of cell therapy

Aims: The purpose of our study is to compare the effects of core decompression (CD) and bone grafting (BG) on osteonecrosis of the femoral head (ONFH). And evaluate the efficacy of CD based on cell therapy to provide guidance for the dose and number of cells. Methods: We searched PubMed, Embase, and the Cochrane Library between 2012 and 2022, with keywords including "osteonecrosis of the femoral head", "core decompression" and "bone grafting". We selected comparative studies of CD and BG, and the comparison of CD combined with bone marrow (BM) transplantation and CD alone. Changes in hip pain were assessed by VAS, hip function were assessed by HHS and WOMAC, and THA conversion rate was used as an evaluation tool for femoral head collapse. From these three aspects, the dose of bone marrow and the number of cells transplantation were subgroup analyzed. Results: Eleven studies were used to compare the efficacy of CD and BG. There was no significant difference in HHS, and the THA conversion rate of BG was significantly lower than that of CD. Thirteen CD studies based on cell therapy were included in the meta-analysis. Bone marrow aspiration concentrate (BMAC) can significantly improve VAS (mean difference (MD), 10.15; 95% confidence intervals (CI) 7.35 to 12.96, p < 0.00001) and reduce THA conversion rate (odds ratio (OR), 2.38; 95% CI 1.26 to 4.47, p = 0.007). Medium dose bone marrow fluid has a lower p-value in THA conversion rate. The p values of bone marrow mononuclear cells (BMMC) of 10⁹ magnitude in VAS score were lower. Conclusion: In general, there is no consensus on the use of BG in the treatment of ONFH. The enhancement of cell-based CD procedure shows promising results. Using 20 mL BMAC and 10⁹ magnitude BMMC is likely to achieve better results.

Comparison of Walking Quality Variables between End-Stage Osteonecrosis of Femoral Head Patients and Healthy Subjects by a Footscan Plantar Pressure System

Background and Objectives: Osteonecrosis of the femoral head (ONFH) is a progressive disease with a complex etiology and unknown pathogenesis. Gait analysis can objectively assess the functional behavior of the foot, thus revealing essential aspects and influencing factors of gait abnormalities. The aim of this study was to evaluate the differences in spatiotemporal parameters, static and dynamic plantar pressure parameters, and symmetry indices between patients with ONFH and healthy subjects. Materials and Methods: The study population consisted of 31 ONFH patients and 31 healthy volunteers. Gait parameters were obtained from the plantar pressure analysis system for both the ONFH and healthy groups. The symmetry index was calculated according to a formula, including spatiotemporal parameters, static and dynamic plantar pressure distribution, percentage of regional impulse, and percentage of the restricted contact area. Results: Compared with healthy controls, patients with ONFH had slower walking speed, shorter step length and stride length, and increased stride time, stance time, and percentage of stance. patients with ONFH had lower plantar static pressure on the affected side and higher contralateral plantar static pressure during stance than controls. During walking, the peak pressures in all regions on the affected side and the peak pressure in the toe 1 and metatarsal 3 regions on the healthy side were lower in ONFH patients than in controls. The percentage of contact area and regional impulse in the heel of both limbs were higher in ONFH patients than in the control group. The symmetry indexes of stride time, stance time, step length, maximum force, impulse and contacted area were significantly increased in ONFH patients compared to controls, with decreased symmetry. Conclusions: Osteonecrosis of the femoral head leads to characteristic changes in plantar pressure distribution. These changes may be interpreted as an attempt by patients with ONFH to reduce the load on the affected limb. Plantar pressure analysis may assist in the diagnosis of ONFH and can provide an objective quantitative indicator for the assessment of subsequent treatment outcomes.

Comparison of minimally-invasive fibular supporting of T-type with traditional bloody iliac flap metastasis for osteonecrosis of the femoral head at ARCO stage II

Purpose

Our research mainly evaluates the clinical efficacy of two surgical methods in the treatment of osteonecrosis of the femoral head (ONFH) at ARCO stage II, aiming to provide optimal hip-preserving treatment of ONFH.

Method

From October 2018 to September 2020, 48 patients (59 hips) met the inclusion criteria and randomized. 24 cases (29 hips) in experimental group were treated with minimally-invasive fibular supporting of T-type; 24 cases (30 hips) in control group were treated with traditional bloody iliac flap metastasis. We will compare some intraoperative and postoperative conditions.

Result

The operation time in experimental group was 37 (6) minutes, in control group was 130 (21.75) minutes; the length of surgical incision in two groups was 3.7 (0.7) cm and 12.85 (2.68) cm. The intraoperative blood loss in two groups was 69 (21) ml and 363 (87) ml; the postoperative VAS score of the experimental group on day 1, day 3, day 7 after surgery was 5.5 (2), 3.5 (1), 0 (1); the control group was 6 (1.75), 4 (1), 3 (1). The data differences between above groups have statistically significant. The follow-up time of two groups was (33.86 ± 5.66) months and (35.67 ± 4.69) months. The bone graft healing time in two groups was (14.21 ± 1.93) months and (13.83 ± 2.34) months. The Harris hip scores of two groups at the last follow-up were 90 (7.5) and 86.5 (8.5). The survival rates of two groups were 79.31% (23/29) and 76.67% (23/30). The difference was no statistically significant in above groups (P > 0.05).

Conclusion

The two different bone graft implantation showed satisfactory early outcomes. Compared to the control group, the experimental group has the advantages of lesser pain, lesser blood loss, lesser trauma and shorter operation time. It may be a choice as bone graft for the treatment of ONFH at early stage.

Rapidly progressive femoral head necrosis due to post-traumatic Brucella hip infection: a case report

Brucellosis is a common zoonotic infectious disease worldwide that can affect almost all organs in the human body. Osteonecrosis of the femoral head has numerous possible causes. Patients usually experience movement disorders, severe pain, and an extremely high disability rate. We herein describe a 32-year-old male farmer living in Shanxi, China who accidentally injured his right hip while working. After 1 month of rest, the pain in the right hip was relieved, and the patient began to walk again. However, after 2 months of walking, he developed aggravated pain and claudication in the right lower limb. Examination revealed shortening of the right lower limb. We carried out a comprehensive and systematic examination and performed total hip arthroplasty. Hip trauma with Brucella infection may progress to osteonecrosis of the femoral head in a short period of time without typical symptoms of Brucella infection. Systematic examination and treatment should be performed at an early stage to prevent the eventual deterioration of the disease and serious complications that are difficult to treat.

The potential effect of BMSCs with miR-27a in improving steroid-induced osteonecrosis of the femoral head

Steroid induced osteonecrosis of the femoral head (ONFH) frequently leads to femoral head collapse and subsequent hip arthritis. This study aimed to investigate the potential therapeutic mechanism of miR-27a on steroid-induced ONFH. Levels of IL-6, TNF-α, miR-27a, Runx2, PPAR-γ and ApoA5 were first examined in bone marrow tissues from steroid-induced ONFH and controls. Subsequently, we overexpressed or knocked down miR-27a in bone marrow mesenchymal stem cells (BMSCs) and detected cell proliferation, osteogenic differentiation, adipogenic differentiation. In addition, miR-27a mimics and BMSCs were injected into the established steroid-induced ONFH rats, and the osteoprotective effects of both were evaluated. Dual luciferase reporter was used to test the targeting effect of miR-27a-3p and PPARG. miR-27a and Runx2 were lowly expressed in steroid-induced ONFH, PPAR-γ and ApoA5 were highly expressed. Overexpression of miR-27a in BMSCs promoted cell proliferation and osteogenic differentiation, inhibited adipogenic differentiation. Furthermore, increasing miR-27a and BMSCs obviously reduced bone loss in steroid induced ONFH rats. The expressions of Runx2 in BMSCs and steroid-induced ONFH rats was significantly up-regulated, while IL-6, TNF-α, PPAR-γ and ApoA5 were down-regulated with miR-27a overexpression. Additionally, PPARG was the target of miR-27a-3p. The results of the present study reveal a role for miR-27a in promoting osteogenesis and may have a synergistic effect with BMSCs.

Serum nicotinamide phosphoribosyltransferase as a novel biomarker for non-traumatic osteonecrosis of the femoral head

OBJECTIVE

The aim of this study was to investigate the potential role of serum nicotinamide phosphoribosyltransferase (NAMPT) in non-traumatic osteonecrosis of femoral head (NONFH).

METHODS

A total of 113 NONFH patients and 81 healthy individuals were included in this study. The NAMPT levels in serum were measured by a commercial enzyme-linked immunosorbent assay kit. Radiographic progression was determined using Association Research Circulation Osseous (ARCO) classification system. Clinical severity was assessed by Harris hip score (HHS) and visual analogue scale (VAS). Correlations between serum NAMPT and radiographic progression as well as clinical severity were evaluated statistically. Receiver operating characteristic (ROC) curves were performed to evaluate the diagnostic values of NAMPT in NONFH potential and disease severity.

RESULTS

The serum NAMPT levels in NONFH patients were significantly lower than that in healthy controls. There were no significant differences among alcohol-induced group, steroids-induced group, and idiopathic group. NONFH patients with ARCO stage 4 had significant lower serum NAMPT levels in comparisons with ARCO stage 3 and 2, respectively. Lower serum NAMPT levels were also observed in bilateral NONFH cases compared with cases with unilateral NONFH. In addition, serum NAMPT was negatively correlated with ARCO stages and VAS scores, and positively correlated with HHS. ROC curve analysis indicated that serum NAMPT may serve as a novel biomarker for diagnosing early NONFH and for monitoring disease severity.

CONCLUSIONS

Our results suggest that serum NAMPT may serve as a novel biomarker for NONFH potential and disease severity.

Does Diabetes Mellitus Increase the Risk of Avascular Osteonecrosis? A Systematic Review and Meta-Analysis

Avascular osteonecrosis (AVN) is caused by the disrupted blood supply to the bone. Most AVN cases occur in the femoral head, but other sites might be affected as well, including the jaw or distal bones of the extremities. Previous studies suggested that diabetes could increase the risk of AVN of the jaw, but the relationship between diabetes and AVN in other bone sites is unclear. This systematic review and meta-analysis aimed to summarize the evidence from studies that had reported on the occurrence of AVN in sites other than the jaw, depending on the diagnosis of diabetes. Overall, we included 6 observational studies carried out in different populations: primary or secondary AVN of the femoral head, Takayasu arteritis, general population, kidney transplant recipients, systemic lupus erythematosus, and primary brain tumors. A random-effects meta-analysis showed that the risk of AVN in sites other than the jaw was non-significantly increased in patients with diabetes (odds ratio: 1.90, 95% confidence interval: 0.93-3.91). The pooled estimate increased and was significant after the exclusion of one study (2.46, 1.14-5.32). There was a significant heterogeneity (I² = 65%, tau² = 0.48, p = 0.01; prediction interval, 0.21-16.84). There was no significant publication bias (p = 0.432). In conclusion, diabetes could increase the risk of AVN in sites other than the jaw, but the available evidence is limited. There is a need for large, well-designed, population-based studies.

[Expert consensus on clinical diagnosis and treatment technique of osteonecrosis of the femoral head (2022 version)]

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in the clinic. Although the exact pathophysiological mechanism is not fully understood, it is believed to be closely related to the interruption of intra-bone circulation and eventual bone tissue death. The prevention and treatment of ONFH is always a great challenge for orthopedists. The diagnostic level of ONFH has been continuously improved with the development of imaging techniques such as MRI and the in-depth understanding of the disease in recent years.There are many treatment methods for ONFH, which are generally considered individually and comprehensively according to factors such as the patient's age, osteonecrosis stage, classification, and compliance with joint-sparing treatment. There is currently no unified standard. ONFH staging and classification play an important reference value for doctors to choose treatment options. In recent years, based on the characteristics of ONFH in Chinese people, the academic community has proposed Chinese staging and China-Japan Friendship Hospital (CJFH) classification. The consensus also introduces them together with the international Association Research Circulation Osseous (ARCO) staging to provide guidance for individualized treatment of ONFH. In order to further standardize the diagnosis of ONFH and expand the treatment of ONFH, the Association Related to Circulation Osseous, Chinese Microcirculation Society (CSM-ARCO) organized domestic experts in the field of ONFH to jointly formulate the expert consensus, in order to provide reference for the standardized diagnosis of ONFH and the selection of individualized diagnosis and treatment techniques.

Emerging roles of growth factors in osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a potentially disabling orthopedic condition that requires total hip arthroplasty in most late-stage cases. However, mechanisms underlying the development of ONFH remain unknown, and the therapeutic strategies remain limited. Growth factors play a crucial role in different physiological processes, including cell proliferation, invasion, metabolism, apoptosis, and stem cell differentiation. Recent studies have reported that polymorphisms of growth factor-related genes are involved in the pathogenesis of ONFH. Tissue and genetic engineering are attractive strategies for treating early-stage ONFH. In this review, we summarized dysregulated growth factor-related genes and their role in the occurrence and development of ONFH. In addition, we discussed their potential clinical applications in tissue and genetic engineering for the treatment of ONFH.

[Research progress of immune cells regulating the occurrence and development of osteonecrosis of the femoral head]

OBJECTIVE

To summarize the characteristics of the occurrence and development of osteonecrosis of the femoral head (ONFH), and to review the important regulatory role of immune cells in the progression of ONFH.

METHODS

The domestic and foreign literature on the immune regulation of ONFH was reviewed, and the relationship between immune cells and the occurrence and development of ONFH was analyzed.

RESULTS

The ONFH region has a chronic inflammatory reaction and an imbalance between osteoblast and osteoclast, while innate immune cells such as macrophages, neutrophils, dendritic cells, and immune effector cells such as T cells and B cells are closely related to the maintenance of bone homeostasis.

CONCLUSION

Immunotherapy targeting the immune cells in the ONFH region and the key factors and proteins in their regulatory pathways may be a feasible method to delay the occurrence, development, and even reverse the pathology of ONFH.

An overview of pathophysiology and treatment options of osteonecrosis of femoral head in sickle cell disease

Osteonecrosis of the femoral head (ONFH) is the most prevalent musculoskeletal pathologic manifestation of sickle cell disease (SCD) resulting in an osteonecrotic event. This review aimed to summarize mechanisms involved in pathophysiology of ONFH and treatment options available in Saudi Arabia to treat SCD patients with complication of osteonecrotic event. The pathophysiology of ONFH include genetic and micro particles involvement. The progression of osteonecrosis involves reduced levels of bioactive compounds in peripheral blood mononuclear cells and elevated CD4+T circulating levels to stimulate pro-inflammatory cytokines contributing to inflammation at target site. Initial treatment approach is pharmacological agents use to mitigate risk. Further, bone morphogenetic protein stimulation initiate bone formation and treatment can be improved with the use of bone morphogenetic protein, total hip arthroplasty and cell therapies. This review provides baseline information for future studies to be carried out in Saudi Arabia to improve treatment options in SCD patients with ONFH.

[Protective effect of Kaempferol on endothelial cell injury in glucocorticoid induced osteonecrosis of the femoral head]

Objective

To explore the effect of Kaempferol on bone microvascular endothelial cells (BMECs) in glucocorticoid induced osteonecrosis of the femoral head (GIONFH) in vitro.

Methods

BMECs were isolated from cancellous bone of femoral head or femoral neck donated voluntarily by patients with femoral neck fracture. BMECs were identified by von Willebrand factor and CD31 immunofluorescence staining and tube formation assay. The cell counting kit 8 (CCK-8) assay was used to screen the optimal concentration and the time point of dexamethasone (Dex) to inhibit the cell activity and the optimal concentration of Kaempferol to improve the inhibition of Dex. Then the BMECs were divided into 4 groups, namely, the cell group (group A), the cells treated with optimal concentration of Dex group (group B), the cells treated with optimal concentration of Dex+1 μmol/L Kaempferol group (group C), and the cells treated with optimal concentration of Dex+5 μmol/L Kaempferol group (group D). EdU assay, in vitro tube formation assay, TUNEL staining assay, Annexin Ⅴ/propidium iodide (PI) staining assay, Transwell migration assay, scratch healing assay, and Western blot assay were used to detect the effect of Kaempferol on the proliferation, tube formation, apoptosis, migration, and protein expression of BMECs treated with Dex.

Results

The cultured cells were identified as BMECs. CCK-8 assay showed that the optimal concentration and the time point of Dex to inhibit cell activity was 300 μmol/L for 24 hours, and the optimal concentration of Kaempferol to improve the inhibitory activity of Dex was 1 μmol/L. EdU and tube formation assays showed that the cell proliferation rate, tube length, and number of branch points were significantly lower in groups B-D than in group A, and in groups B and D than in group C ( P<0.05). TUNEL and Annexin V/PI staining assays showed that the rates of TUNEL positive cells and apoptotic cells were significantly higher in groups B-D than in group A, and in groups B and D than in group C ( P<0.05). Scratch healing assay and Transwell migration assay showed that the scratch healing rate and the number of migration cells were significantly lower in groups B-D than in group A, and in groups B and D than in group C ( P<0.05). Western blot assay demonstrated that the relative expressions of Cleaved Caspase-3 and Bax proteins were significantly higher in groups B-D than in group A, and in groups B and D than in group C ( P<0.05); the relative expressions of matrix metalloproteinase 2, Cyclin D1, Cyclin E1, VEGFA, and Bcl2 proteins were significantly lower in groups B-D than in group A, and in groups B and D than in group C ( P<0.05).

Conclusion

Kaempferol can alleviate the damage and dysfunction of BMECs in GIONFH.

Therapeutic effect of human umbilical cord mesenchymal stem cells in early traumatic osteonecrosis of the femoral head

Background

Osteonecrosis of the femoral head (ONFH) is a refractory disease due to its unclear pathomechanism. Therapies during the early stage of ONFH have not achieved satisfactory results. Therefore, this study aims to explore the available evidence for the therapeutic effect of human umbilical cord mesenchymal stem cells (HUCMSCs) on early-stage traumatic ONFH.

Methods

Early-stage traumatic ONFH was established. The femoral heads of rats were then locally administered HUCMSCs. Four weeks and eight weeks after surgery, bone repair of the necrotic area in the femoral head was analyzed to evaluate the therapeutic effect of HUCMSCs using micro-CT, histopathological staining, immunofluorescence staining, Luminex.

Results

HUCMSCs were still present in the femoral head four weeks later, and the morphological, micro-CT and histopathological outcomes in the 4-week HUCMSC-treated group were better than those in the model, NS and 8-week HUCMSC-treated groups. Local transplantation of HUCMSCs promoted bone repair and prevented bone loss in the necrotic area of the femoral head.

Conclusions

HUCMSCs can survive and positively affect the femoral head through local transplantation in early-stage traumatic ONFH. The conclusions of this study can provide a treatment option for patients who have ONFH and can serve as basic research on the advanced development of this disease.

The Translational potential of this article

The study indicated that the positive effect of exogenous HUCMSCs in the treatment of early-stage traumatic ONFH provides the solid basis and guidance for the clinical application of HUCMSCs.

SIRT6 Prevents Glucocorticoid-Induced Osteonecrosis of the Femoral Head in Rats

Objective

Glucocorticoid-induced osteonecrosis of the femoral head is one of the most common causes of nontraumatic osteonecrosis of the femoral head, but its exact pathogenesis remains unclear. The aim of this study was to investigate the role of SIRT6 in the maintenance of bone tissue morphology and structure, intravascular lipid metabolism, and its potential molecular mechanism in glucocorticoid-induced osteonecrosis of the femoral head.

Methods

SIRT6 adenovirus was transfected into GIONFH in rats. The microstructure of rat bone was observed by micro-CT and histological staining, and the expression of bone formation-related proteins and angiogenesis-related factors was determined through western blot and immunohistochemistry. Alkaline phosphatase activity, alizarin red staining, and the expression levels of Runx2 and osteocalcin were used to evaluate the osteogenic potential. And in vitro tube formation assay and immunofluorescence were used to detect the ability of endothelial cell angiogenesis.

Results

Dexamethasone significantly inhibited osteoblast differentiation, affected bone formation, and destroyed microvessel formation, increased the intracellular Fe²⁺ and ROS levels and induced the occurrence of ferroptosis. SIRT6 can inhibit ferroptosis and restore the ability of bone formation and angiogenesis.

Conclusion

SIRT6 can inhibit the occurrence of ferroptosis, reduce the damage of vascular endothelium, and promote osteogenic differentiation, so as to prevent the occurrence of osteonecrosis of the femoral head.

[Short hip stem for THA in avascular necrosis of the femoral head]

INTRODUCTION

Osteonecrosis of the femoral head or avascular necrosis of the femoral head (HKN) is a complex disease that, without treatment, leads to infraction of the femoral head in most cases. In these cases, only replacement of the hip joint will help, although there is no clear recommendation of an arthroplasty type. In the last two decades, the treatment of primary and secondary coxarthrosis with short-shaft prostheses with different anchoring philosophies has increased. Since short-shaft fitting is a possible option especially in younger patients, the question arises about possible fittings of advanced HKN with these stem types, especially with metaphyseal anchorage. The aim of this study was to review the existing literature on the results of short stem prosthesis in HKN and to present the advantages and disadvantages of short stem prosthesis in osteonecrosis of the femoral head.

MATERIAL AND METHODS

This review analyzes the existing studies on short stem arthroplasty for HKN.

RESULTS

Only a few studies exist that have analyzed clinical and radiologic outcomes of short stem replacement in HKN.

CONCLUSION

The existing short- and medium-term results show mostly good outcomes. However, it is difficult to draw a general conclusion due to differences in stem design and fixation. Short stems with primary diaphyseal fixation do not show an increased risk of failed osseointegration or loosening. Constructions with primary metaphyseal fixation should undergo MRI to rule out the possibility of necrosis extending beyond the femoral neck.

Impaction Bone Grafting Augmented With a Wire Coil by the Lightbulb Technique for Osteonecrosis of the Femoral Head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a debilitating disease that primarily affects the hips of young adults. The purpose of this study is to report the mid-term results of impaction bone grafting augmented with a wire coil using the lightbulb technique for ONFH.

METHODS

From 1998 to 2016, 50 hips with late precollapsed or early postcollapsed ONFH (28 hips with Association Research Circulation Osseous [ARCO] IIC and 22 with IIIA) were treated by impaction bone grafting augmented with a wire coil using the lightbulb technique. The survival rate was analyzed with conversion to total hip arthroplasty (THA) as the end point.

RESULTS

Thirty-one of the 50 hips had a successful clinical result without conversion to THA at a mean follow-up of 109.2 months. The 5-year survival rate was 68%, 82.1%, and 50% for the entire cohort, ARCO stage IIC, and ARCO stage IIIA, respectively. The 19 hips that had failed were converted to THA at an average of 52.8 months. The multivariable Cox proportional hazards model showed that an ARCO stage IIIA disease, a lateral lesion, and a necrotic index ≥0.67 were the independent risk factors for conversion to THA.

CONCLUSION

As a head-preserving procedure, the lightbulb technique using impaction bone grafting augmented with a wire coil is worthwhile for patients in an earlier stage of disease and smaller lesion size to postpone the need for THA.