Osseous avascular necrosis associated with systemic abnormalities

Coexisting Kienböck's and Preiser's Disease of the Wrist: Experience with Proximal Row Carpectomy with Dorsal Capsular Interposition Technique

BACKGROUND

Idiopathic avascular necrosis of the lunate is known as Kienböck's disease and that of the scaphoid is known as Preiser's disease. Because the prevalence of coexisting Kienböck's and Preiser's diseases is very low, standardized stages of disease and treatments are not established.

CASE PRESENTATION

We report coexisting avascular necrosis of the scaphoid and lunate in a 68-year-old woman with no history of steroids or other risk factors. We treated her with proximal row carpectomy with capsular interposition technique. A distal-based dorsal capsular flap was prepared and repaired the palmar capsule. At the last follow-up, she had no pain and had gained improved range of wrist motion. There was no arthritic change at the newly formed radiocapitate joint.

CONCLUSIONS

In the case of collapsed lunate and scaphoid with avascular necrosis, the proximal row carpectomy procedure has an advantage. Proximal row carpectomy with dorsal capsular interposition can be performed when the lunate or scaphoid cannot be saved. Arthritic changes of the capitate head and distal radius lunate facet can be covered with the dorsal capsule.

Systems analysis of avascular necrosis of femoral head using integrative data analysis and literature mining delineates pathways associated with disease

Avascular necrosis of femoral head (AVNFH) is a debilitating disease, which affects the middle aged population. Though the disease is managed using bisphosphonate, it eventually leads to total hip replacement due to collapse of femoral head. Studies regarding the association of single nucleotide polymorphisms with AVNFH, transcriptomics, proteomics, metabolomics, biophysical, ultrastructural and histopathology have been carried out. Functional validation of SNPs was carried out using literature. An integrated systems analysis using the available datasets might help to gain further insights into the disease process. We have carried out an analysis of transcriptomic data from GEO-database, SNPs associated with AVNFH, proteomic and metabolomic data collected from literature. Based on deficiency of vitamins in AVNFH, an enzyme-cofactor network was generated. The datasets are analyzed using ClueGO and the genes are binned into pathways. Metabolomic datasets are analyzed using MetaboAnalyst. Centrality analysis using CytoNCA on the data sets showed cystathionine beta synthase and methylmalonyl-CoA-mutase to be common to 3 out of 4 datasets. Further, the genes common to at least two data sets were analyzed using DisGeNET, which showed their involvement with various diseases, most of which were risk factors associated with AVNFH. Our analysis shows elevated homocysteine, hypoxia, coagulation, Osteoclast differentiation and endochondral ossification as the major pathways associated with disease which correlated with histopathology, IHC, MRI, Micro-Raman spectroscopy etc. The analysis shows AVNFH to be a multi-systemic disease and provides molecular signatures that are characteristic to the disease process.

Intervertebral disk nutrition: a review of factors influencing concentrations of nutrients and metabolites

The biomechanical behavior of the intervertebral disk ultimately depends on the viability and activity of a small population of resident cells that make and maintain the disk's extracellular matrix. Nutrients that support these cells are supplied by the blood vessels at the disks' margins and diffuse through the matrix of the avascular disk to the cells. This article reviews pathways of nutrient supply to these cells; examines factors that may interrupt these pathways, and discusses consequences for disk cell survival, disk degeneration, and disk repair.

Avascular necrosis of bone--a complication of aggressive therapy for acute lymphoblastic leukemia

The purpose of the present paper was to report cases of avascular necrosis of bone (AVNB) arising as a complication of chemotherapy for acute lymphoblastic leukemia (ALL). X-rays and 99mtechnicium-MDP bone scans were performed on patients with symptoms of bone pain, whereby five patients out of 850 patients were detected to have avascular necrosis of the femoral head. All had received aggressive chemotherapy with steroids. Two patients were still on therapy for the primary disease. In these patients further chemotherapy was continued without steroids. The median period from diagnosis of ALL to development of AVNB was 29 months. Three patients underwent corrective surgical procedures. To conclude, the data suggest that patients receiving combination chemotherapy, especially those with high cumulative doses, run a risk of developing AVNB. Awareness of this complication is important in order to have an early diagnosis so as to limit disability.

Management of osteonecrosis of the femoral head

Osteonecrosis of the femoral head continues to pose a therapeutic challenge to orthopedic surgeons. This pathologic process results from the death of living components of bone from mechanical and biologic factors. Diagnosis, clinical symptoms, and classification systems are discussed. Several treatment regimens and their controversies are explored in this article.

Avascular necrosis of the proximal carpal row. A case report

Avascular necrosis of bone has been described in many sites, including the carpal bones. The case history of a patient with avascular necrosis of the entire proximal row, previously undescribed, is detailed. Numerous contributing factors, including steroid administration, hyperlipidemia, and systemic lupus erythematosus are noted. Occult wrist pain in any patient with known risk factors for avascular necrosis is a warning sign; early bone scan may help prevent late complications.

The early diagnosis of ischemic necrosis of bone

One hundred sixty-nine patients with radiographic or histologic evidence of ischemic necrosis of bone (INB) were evaluated. Ninety-nine (59%) of the 169 patients had multiple sites of INB, with 310 bones affected. Two hundred sixty-three (85%) of the 310 ischemic bones were symptomatic. Routine radiography produced negative findings in 58 (20%) of the bones with histologically confirmed INB. Results of hemodynamic studies, including baseline bone marrow pressure, saline stress test, and/or intraosseous venography, were abnormal in 243 (94%) of 259 ischemic bones so evaluated. Most importantly, hemodynamic studies detected 51 (93%) of the 55 bones that were radiographically normal but had histologically confirmed INB.

Early treatment of avascular necrosis in systemic lupus erythematosus

Avascular necrosis (AVN) of the hips is associated with significant disability, and the majority of established cases require major surgery. In a retrospective analysis of 185 patients with systemic lupus erythematosus (SLE) 13 (7%) were found to have AVN. Of these, six had Raynaud's phenomenon, all had been on corticosteroids, and one had digital vasculitis. The mean duration of corticosteroid therapy was two years (range four months to five years). Five patients developed AVN two to 10 years after discontinuing steroids. The mean duration of disease at the onset of AVN was 6.85 years (range 1-19 years), and the mean age at onset of AVN was 31 years. Ten patients had severe multisystem involvement. None of the patients abused alcohol. Surgery was performed on 11 hips. Three had total hip replacement for stages 3 and 4 and seven had core decompression for stages 1 and 2. AVN progressed in two (28%) of these patients. In another patient core decompression failed for technical reasons. She subsequently required total hip replacement. The early detection of AVN to avoid the need for major surgery is stressed.

Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus

In this prospective study, 28 (52 percent) of 54 patients with systemic lupus erythematosus (SLE) had ischemic necrosis of bone in 93 sites. All but two of the patients had multiple sites of involvement, with hips, knees, and shoulders affected in decreasing order of frequency. Demographic, clinical, and laboratory features were comparable in patients with and without ischemic necrosis of bone except for cushingoid changes in 24 (86 percent) of the 28 patients with ischemic necrosis of bone versus four (15 percent) of the 26 patients without ischemic necrosis of bone (p less than 0.0001). The duration of steroid therapy, total cumulative steroid dose, and the mean daily prednisone dose for the first one, three, six, and 12 months of therapy were not significantly different between the two groups. Mean daily prednisone dose for the highest single month as well as the highest consecutive three, six, and 12 months of therapy was significantly higher in patients with ischemic necrosis of bone. The mean daily dose of prednisone for the highest month of therapy was greater than 40 mg per day in 93 percent and greater than 20 mg per day in all patients with ischemic necrosis of bone. In patients with ischemic necrosis of bone, there was a statistically significant correlation between higher mean prednisone dose at all time intervals and increased number of bony sites involved. A lower mean dose of prednisone was required to produce ischemic necrosis of bone in patients with Raynaud's phenomenon.

Alcohol consumption in arthritic patients: clinical and laboratory studies

In popular belief patients with chronic arthritis take alcohol for its analgesic effect. To test this we studied by validated questionnaire the past and present alcohol consumption of 103 patients with primary osteoarthritis of the hip (OA), 95 patients with rheumatoid arthritis (RA), and 90 orthopaedic non-arthritic controls. OA men were most likely and RA men least likely to have been heavy drinkers at any time of their lives. Mean red corpuscular volume (MCV), gamma-glutamyltransferase (GGT), and serum uric acid (SUA) levels did not correlate with reported alcohol consumption. Two of 93 OA femoral heads examined had avascular change; both were from heavy drinkers. The abstemiousness of RA men compared with their OA counterparts was due to a striking increase in joint pain after drinking alcohol (p = 0.004), fear of adverse drug reactions with alcohol, and a widespread belief not expressed by OA men that 'alcohol and arthritis do not mix'.

Avascular necrosis of bone following combination chemotherapy for acute lymphocytic leukemia

Avascular necrosis of bone (AVNB) is a known complication of systemic adrenocorticosteroid therapy, and one which is thought to be dose-related. However, despite the large amounts of prednisone which have been used in the standard treatment of acute lymphocytic leukemia (ALL), AVNB rarely has been reported in children with that disease. We described our experience with one adolescent with ALL who developed multifocal AVNB presenting as bone pain after aggressive chemotherapy that included a high cumulative dose of corticosteroids as well as other antitumor agents, some of which also have been associated with AVNB. Four similar cases from the literature are reviewed. Because the bone pain of AVNB can mimic that of leukemic relapse, this is an important entity to be aware of, and one which may become more common with increasingly aggressive combination chemotherapy.

Idiopathic avascular necrosis of the scaphoid. Case report

Avascular necrosis may affect a number of different bones. In the wrist necrosis of the lunate (Kienböck's disease) is a well known entity. A rarely seen but analogous condition may, however, also affect the scaphoid (Preiser's disease). The mechanism producing ischemia is unknown, although in most cases the initiating event is mostly likely loss of blood supply by a mechanical insult. Two cases of idiopathic avascular necrosis of the scaphoid are reported, manifested by insidious wrist pain and progressing roentgenologic changes. Despite early diagnosis and prolonged immobilization irreversible collapse of the affected bone could not be prevented.

Aseptic necrosis presenting as wrist pain in SLE

Aseptic necrosis of the wrist in systemic lupus erythematosus (SLE) is not rare. In 156 patients with SLE, aseptic necrosis occurred in 11 patients, of whom 3 (27%) had wrist involvement. Onset of pain was insidious and the symptoms were thought to be related to synovitis due to SLE. An average of 11 months elapsed before aseptic necrosis was correctly diagnosed. An awareness of this possibility is important in the management of any patient with SLE who complains of wrist pain.

Osteonecrosis of the femoral head in patients with lymphoma treated with intermittent combination chemotherapy (including corticosteroids)

Four adult patients with malignant lymphoma were treated with combination chemotherapy including an alkylating agent, vincristine, procarbazine (in all but one case), and intermittent high-dose prednisone. Twenty to 42 months after initiation of therapy, osteonecrosis of the femoral head developed. This was bilateral in two patients and unilateral in two, and presumably represented a complication of steroid administration, even though three of the patients received only 4 to 6 weeks of therapy. Necrosis of bone may be a low-frequency long-term complication of combination chemotherapy in lymphoma.