Pregnancy and post-pregnancy avascular necrosis of the femoral head

The correlation between transient osteoporosis of the hip and pregnancy: A review

Transient osteoporosis of the hip is indubitably a comparatively infrequent entity affecting both men and women worldwide. Its occurrence in the course of pregnancy, specifically in the third trimester, and lactation are of paramount concernment. The exact association between transient hip osteoporosis and pregnancy is precarious. Etiology and potential pathophysiological mechanisms behind this correlation are still to be utterly defined. Magnetic resonance imaging is highly regarded as the gold standard imaging method for assiduous assessment of this disorder. Physicians of copious medical specialties should practice scrupulous techniques for early and pertinent diagnosis when pregnant women are presented with persistent hip pain, as differential diagnosis with femoral head avascular necrosis can be exceedingly arduous. Treatment is predominantly conservative with protected weight-bearing and analgesic medication in the first line of management. In terms of prognosis, the disease ordinarily resolves spontaneously after a few months. Further research is required in order to elucidate the ambiguity surrounding the establishment of globally approved diagnosis and treatment guidelines for pregnancy-associated transient hip osteoporosis. This paper aims to accentuate the significance of this particular disorder by providing a succinct review of the existing literature, augmenting clinicians' knowledge about the features of pregnancy-related transient proximal femur osteoporosis.

Hip avascular necrosis in a healthy pregnant woman: A case report and review of literature

Background

Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity.

Case report

We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age.

Discussion

With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called “Pelvic pain syndrome” and transient osteoporosis of the hip.

Conclusion

Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications.

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Corticosteroids and alcohol intake are the most common atraumatic cause of hip osteonecrosis

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Hip and pelvic pain during pregnancy are very frequent and may hide a serious event such as hip avascular necrosis

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Hip avascular necrosis can have disastrous complications if not diagnosed in young pregnant women.

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Having a high index of suspicion in a pregnant woman with hip pain is a must to prevent such complications

Avascular femoral necrosis as part of Cushing syndrome presentation: a case report

Background

The clinical characteristics and complications of Cushing syndrome (CS) are well known and described in the literature. Nevertheless, rare, atypical presentations may go unnoticed. Osteonecrosis is a well-documented complication of glucocorticoid therapy. However, endogenous hypercortisolism is a rare, but relevant, cause of bone avascular necrosis. We describe the case of a woman with CS undiagnosed for 2 years after presenting with femoral avascular necrosis.

Case presentation

A 38-year-old Caucasian woman was referred for evaluation of secondary amenorrhea, associated with oral contraception withdrawal in the context of deep venous thrombosis (DVT). She had a previous right hip arthroplasty for treatment of avascular necrosis of the femoral head, diagnosed after 3 years of progressive right hip pain and limited mobility. She also had high blood pressure (HBP) of 5 years’ duration, and reported weight gain (4 kg in 2 years). There was no history of infertility (gravida 2, para 2). Physical examination revealed buffalo hump, truncal obesity, facial plethora, muscular atrophy and proximal myopathy, and easy bruising (under anticoagulant treatment for DVT). Workup showed abnormal overnight dexamethasone suppression test (DST) (serum cortisol 21.5 µg/dL; normal < 1.8 µg/dL), elevated 24-hour urinary free cortisol (UFC) (728.9 µg/day; reference range 36.0–137.0 µg/day), and suppressed plasma adrenocorticotropic hormone (ACTH) (< 1.0 pg/mL), findings consistent with ACTH-independent CS. Urinary metanephrines and catecholamines were normal, and the remaining analytical study showed no major changes, apart from glycated hemoglobin (HbA1c) of 6.8%. Adrenal computed tomography (CT) scan showed a 25 mm lesion in the left adrenal gland, with density non-suggestive of adenoma. The patient underwent unilateral adrenalectomy and started steroid replacement. Histology revealed an adrenal cortex adenoma. Three months after surgery the patient presented with resolution of HBP and hypercortisolism (UFC 37.4 µg/day; reference range 36.0–137.0 µg/day).

Conclusion

In some cases, CS signs may go unnoticed and the diagnosis postponed. Avascular necrosis is a rare presenting feature of endogenous hypercortisolism, and, if left untreated, complete collapse of the femoral head may ensue, rendering the need for hip replacement in up to 70% of patients. Suspicion and recognition of atypical features is therefore important in avoiding complications and delay in treatment of CS.

Community-based non-pharmacological interventions for improving pain, disability and quality of life in pregnant women with musculoskeletal conditions: protocol for a systematic review with meta-analyses

INTRODUCTION

Twenty five per cent of pregnant women with musculoskeletal pain have disabling symptoms that negatively influence quality of life. Studies have reported varying effects of non-pharmacological interventions including exercise, manipulation and pelvic belts for pregnant women with musculoskeletal problems. The overall effectiveness and acceptability of these interventions is uncertain due to lack of synthesised evidence. This protocol is for the first systematic review of community-based non-pharmacological interventions for improving pain, disability and quality of life in pregnant women with musculoskeletal conditions from studies published until August 2020.

METHODS AND ANALYSIS

A detailed search of PubMed, CINAHL, CENTRAL, Global Index Medicus, African Index Medicus, African Journal Online, Western Pacific Region Index Medicus, Latin American and Caribbean Centre on Health Science Information, Index Medicus for South-East Asia Region, IRIS (WHO digital publications), British Library for Development Studies and Google Scholar. Additional studies will be located from the reference list of identified studies and relevant systematic reviews. The databases will be searched from inception to August 2020. Appraisal of study quality will be performed with the Mixed Methods Appraisal Tool. Data will be synthesised using a mixed-studies synthesis design-the convergent synthesis. The description of interventions in all study designs will be summarised narratively. Meta-analyses will be used to statistically summarise the effectiveness of interventions in randomised controlled trials and the factors that influence these. Other quantitative studies will be summarised narratively to answer the objectives. Thematic synthesis will be used to summarise results of qualitative studies. The outcomes of interest include pain, disability and quality of life. This paper is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols 2015 guidelines.

ETHICS AND DISSEMINATION

Ethical clearance is not required. Findings will be presented at conferences and published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42020189535.

Zoledronic acid for the treatment of pregnancy-associated femoral head necrosis: A case report

Introduction

The management of pregnancy-associated femoral necrosis is controversial. Conservative management may eventually lead to hip replacement.

Case

A 40-year-old woman developed necrosis of the left hip during her first pregnancy. Treatment with zoledronic acid three months after delivery resulted in rapid reduction of the necrotic area. The patient's second pregnancy shortly afterwards had no complications. A magnetic resonance scan three years later documented complete resolution.

Conclusion

Femoral head necrosis should be suspected in the differential diagnosis of pain in pregnancy. Zoledronic acid given in the early stages prevented progression to hip arthritis in this case.

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Osteonecrosis of the femoral head must always be taken into account in the differential diagnosis of hip pain in pregnancy.

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Conservative treatment of pregnancy-associated osteonecrosis may lead to hip replacement.

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A prompt treatment may be essential to prevent arthroplasty.

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We report for the first time a case of femoral osteonecrosis treated with zoledronate in a primigravid woman.

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Zoledronic acid proved safe and effective and the outcome persisted throughout the duration of a second pregnancy.

Bilateral Osteonecrosis of the Femoral Head During Pregnancy Following Two Corticosteroid Injections: A Case Report and Review of the Literature

Osteonecrosis of the femoral head during pregnancy, or shortly thereafter, is a rare clinical problem. Little is known about pregnancy as an etiological factor for femoral head osteonecrosis with only 40 reported cases in the literature. Furthermore, single or dual dose steroid-induced multifocal osteonecrosis is a controversial topic with only a handful of published cases. We present a case of a 34-year-old female with bilateral femoral head osteonecrosis that developed during the peripartum period. She received two large intramuscular injections of steroids for fetal lung maturity because early delivery was required as a result of eclampsia. She underwent total arthroplasty of the left hip due to unremitting pain and functional disability, which achieved good clinical results--relieving her pain and improving her range of motion. Literature is scarce with regard to single or dual dose steroid-induced osteonecrosis of the hip as well as pregnancy as a general etiologic factor. This case highlights the need for high clinical suspicion of osteonecrosis as a cause of postpartum hip pain.

Static and dynamic biomechanical adaptations of the lower limbs and gait pattern changes during pregnancy

The purpose of this literature review is to evaluate the studies that have investigated static and dynamic biomechanical changes of the lower limbs and gait patterns during pregnancy. Original articles on this subject, published between 1934 and 2012, were considered. In general, pregnant women demonstrated greater hip flexion, more extended knees and less plantar flexion ankles. These changes could explain the gait patterns of pregnant women characterized by increased hip angles, decreased propulsion forces associated with increased durations of stance phase and changes in distributions of the plantar loads with increased loads in the forefoot and decreased ones in the rearfoot. This can lead to arthrokinematic deviations that, with time, contribute to the development of musculoskeletal discomfort. In summary, these findings showed the importance of further longitudinal studies to investigate the relationships between musculoskeletal discomfort in pregnant women in the lower limbs and gait changes observed throughout this period.

Lower extremity changes experienced during pregnancy

The anatomic and physiologic changes occurring with pregnancy result in a variety of symptoms affecting the lower extremity. The purpose of this investigation is to provide a comprehensive look at the lower extremity changes experienced during pregnancy and correlate symptoms with underlying etiology in a literature review. In this retrospective study, 100 postpartum women were interviewed regarding the lower extremity changes experienced in pregnancy. The interview included dermatologic, vascular, neurologic, and musculoskeletal portions. Results demonstrate more than 50% of women reported faster toenail growth, roughened toenail texture, increased dryness of the skin, swelling of the foot, ankle, and leg, unsteady gait, increased foot width, and hip pain. Though a majority of patients did not experience the remaining symptoms represented in the interview, all results are pertinent and deserve understanding to provide better insight and care for the pregnant woman. Therefore, a thorough literature review is presented to correlate the outcomes of the present study with previously published research.

Hip fracture in a patient affected by transient osteoporosis of the femoral head during the last trimester of pregnancy

Few cases of hip fracture in pregnant women affected by transient osteoporosis of the femoral head have been reported in the literature, but its real incidence seems to be underestimated. During pregnancy, osteoporosis manifests itself with an insidious onset of hip pain and limp without any trauma or infective episode in clinical history. Its clinical course is characterized by spontaneous recovery a few weeks to several months after delivery. This article describes the case of a 35-year-old woman with a sudden onset of bilateral hip pain during the last trimester of her first pregnancy; she had neither history of steroid therapy nor alcohol abuse; her body temperature and serological parameters were normal. Bilateral transient osteoporosis of the femoral heads was suspected and confirmed by magnetic resonance imaging. Fifteen days postpartum, she was admitted to our clinic with a displaced femoral neck fracture. A cementless total hip arthroplasty was performed to quickly begin a rehabilitative program. She underwent antiresorptive therapy with alendronic acid 70 mg/week and vitamin D for 3 months. Three months after the fracture, a dual-energy x-ray absorptiometry scan showed osteopenia (T-score, -1.5). Risedronic acid 35 mg/week and vitamin D were then prescribed. The last physical examination at 3 months postoperatively revealed a gradual recovery of the autonomy in activities of daily life.

Bilateral osteonecrosis of the femoral head associated with pregnancy: four new cases and a review of the literature

Osteonecrosis is thought to result from the temporary or permanent loss of blood supply to the bones. Without proper nutrition, the bone tissue dies, is resorbed, and collapses. If the process involves the bones in a joint, it often leads to collapse of the joint surface. Four new cases of bilateral osteonecrosis of the femoral head occurring during pregnancy are described, with pathologic examination of core tissue biopsy substantiating the diagnoses. Operative and nonoperative management included anti-inflammatory medication, pulsating electromagnetic fields, core decompression, and total hip replacement. A review of the literature is undertaken to document the reported cases of osteonecrosis of the femoral head associated with pregnancy. Idiopathic osteoporosis of the femoral head is a condition that mimics osteonecrosis of the femoral head and can be a challenge in diagnosis during the latter stages of pregnancy. Bilateral osteonecrosis of the femoral head during pregnancy is rare. Patients may have other predisposing factors leading to femoral head necrosis. Transient osteoporosis of the femoral head during pregnancy can present with a clinical picture similar to osteonecrosis. Avascular necrosis of the femoral head should be considered in the differential diagnosis of pain about the hip developing during pregnancy or in the immediate postpartum period.

Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum

Gender-specific care of musculoskeletal impairments is increasingly important in women's health. This is most relevant and of paramount importance as it relates to identification and management of musculoskeletal and peripheral neurologic disorders of pregnancy, delivery, and postpartum. The specific anatomic and physiologic changes of pregnancy predispose to a specific set of diagnoses. Virtually all women experience some degree of musculoskeletal discomfort during pregnancy. This article provides an overview of the more common pregnancy-related musculoskeletal conditions and includes a discussion of epidemiology, risk factors, diagnosis, prognosis, and management.

Bilateral osteonecrosis of the femoral head after pregnancy

Published cases of non-traumatic avascular necrosis of the femoral head associated with pregnancy are rare. We report a case of a 41-year-old woman who suddenly complained of bilateral hip pain 3 weeks after delivery by Caesarean section. For a problem of sterility, she had been treated with human menopausal gonadotropin and human chorionic gonadotropin (hMG-hCG). Initial radiographs of both hip joints were considered regular. After 4 years' evolution, radiographs of the hip joint showed collapse of both femoral heads. Bilaterally, osteonecrosis of the femoral heads was confirmed by MRI. MRI revealed a band pattern of low signal intensity for both hips on T1- and T2-weighted images. She had no history of steroid therapy or alcohol abuse. Osteonecrosis was related to pretentaine. A bilateral total hip arthroplasty was performed. The literature about avascular necrosis of the femoral head associated with pregnancy in previous cases is reviewed.

Musculoskeletal aspects of pregnancy

Sex-specific care of musculoskeletal impairments is an increasingly important topic in women's health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.

Pathogenesis and natural history of osteonecrosis

BACKGROUND AND OBJECTIVES

Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment.

METHODS

A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited.

RESULTS

Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one.

CONCLUSIONS

Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis.

RELEVANCE

A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options.

Postpartum Multifocal Avascular Necrosis: What Are the Possible Etiologies?

Avascular necrosis of bone (osteonecrosis) that is atraumatic is most frequently associated with corticosteroid excess or alcoholism and usually involves the femoral head. We report a case of multifocal avascular necrosis in a 38-year-old woman with autoimmune Addison's disease taking corticosteroid replacement therapy. The onset of joint symptoms occurred 6 months after a pregnancy complicated by acute fatty liver and disseminated intravascular coagulation. Although both knees and ankles were involved, an unusual feature is that the hips were spared. As illustrated in this patient, avascular necrosis is frequently misdiagnosed in cases of joint pain of acute onset and may occur in the context of physiologic replacement doses of corticosteroids. Etiologic factors can precede the onset of symptoms and the diagnosis by several months.

Osteonecrosis of the femoral head associated with pregnancy. A preliminary report

BACKGROUND

Osteonecrosis is usually associated with trauma, use of corticosteroids, or alcohol abuse. We investigated the rare association of osteonecrosis of the femoral head and pregnancy, and we defined differences between the disorder in pregnant women and that in women of childbearing age who were not pregnant. The results of treatment with a free vascularized fibular graft were evaluated in terms of relief of pain and improvement of the Harris hip score after a minimum of two years of follow-up.

METHODS

Thirteen women (seventeen hips) had the onset of pain in the hip during pregnancy or within the first four weeks after delivery, and the pain persisted until a diagnosis of osteonecrosis of the femoral head was made on the basis of magnetic resonance imaging. No patient had any other risk factor for this disease. Information was obtained by means of clinical assessment, a review of the records and radiographs, and a telephone survey. Eleven women (fifteen hips) were managed with a free vascularized fibular graft, and nine of them (eleven hips) were evaluated, with regard to relief of pain and the Harris hip score, at a minimum of two years postoperatively.

RESULTS

The average age when the pain began was 31.5 years (range, twenty-five to forty-one years). Eleven of the thirteen women were primigravid, and the patients typically first had the pain late in the second trimester or in the third trimester of pregnancy. The women tended to have a small body frame and a relatively large weight gain during the pregnancy. Eight of the thirteen patients had swelling and varicosity of the lower extremities. The diagnosis was delayed an average of 10.3 months, with a range of three to thirty months. A common misdiagnosis was transient osteoporosis of the hip during pregnancy. A correct diagnosis was established for all hips on the basis of the finding of a double-density signal on magnetic resonance imaging or evidence of progression of the disease on plain radiographs. According the system of Marcus et al., the stage at the time of diagnosis ranged from II to V. All women had involvement of the left hip, and four had bilateral involvement. Of the eleven women (fifteen hips) who were managed with a free vascularized fibular graft, nine noted marked or complete relief of the preoperative pain. Two hips in a patient who had progressive pain were treated with a total hip arthroplasty. Two hips (one patient) were lost to follow-up. The nine patients (eleven hips) who were available for follow-up at a minimum of two years had an average improvement in the Harris hip score of 24 points.

CONCLUSIONS

Occasionally, pain in the hip that begins during pregnancy is caused by osteonecrosis of the femoral head. A high index of suspicion and use of magnetic resonance imaging may lead to an earlier diagnosis and a better prognosis in this population of women. In this study, treatment with a free vascularized fibular graft was a useful option with which to obviate or postpone the need for total hip arthroplasty.

Aseptic necrosis of the femoral head associated with pregnancy; a case report

A documented case of beginning aseptic necrosis of the femoral head associated with pregnancy together with a review of the literature about this rare complication of pregnancy is presented. The patient complained of increasing pain in the right hip and limitation of movement of the affected joint. After delivery, the diagnosis of beginning avascular necrosis of the right femoral head was confirmed on X-ray, technetium-99 bone scan and CT-scan of the hips. Three weeks after delivery the patient was treated with drilling of the femoral head. Recovery was complete.

[Aseptic necrosis of the femoral head in young adults]

Aseptic necrosis of the femoral head is a well-defined entity. The underlying diseases originate from very different types of pathological conditions. Alcoholism, cortisone therapy, gout or hyperuricemia, sickle cell anaemia and others all lead, through various pathways, to the impairment of the medullary blood flow. In many instances, a compartment syndrome can be demonstrated in the femoral head. Death of the osteocytes follows bone marrow necrosis. Revascularisation originates in the periphery of the necrotic segment. Vascular buds and fibroblasts invade the medullary space. New bone is laid over the necrotic trabeculae. Mechanical failure results from changes in the bony framework at three different levels. The subchondral boneplate may be weakened by the process of revascularisation, the necrotic trabeculae may fail because of diminished stiffness and strength, and overloading has been demonstrated at the junction between dead and living bone. Elevation of the intramedullary pressure is the first objective sign of impending or established bone necrosis. Scintigraphy with Technetium 99 m - Sulphur colloid can now show the early stages of marrow necrosis. Roentgenographic changes only appear in a later phase of the disease. Aseptic necrosis must be considered as involving both hips, unless proven otherwise. Attention given to the "silent hip" may allow salvage and prevent the occurrence of osteo-arthritic changes leaving merely unilateral disease. As long as the geometrical shape of the femoral head is maintained operation may well prove useful. The aim at this stage is to prevent collapse. It is impossible to know in the early stages whether mechanical failure will occur, but there is general agreement that the femoral head will eventually undergo deformation. A spherical epiphysis is therefore considered a success. All the conservative methods aim to decompress the medullary cavity. Core biopsy, curettage, bone grafting and intertrochanteric osteotomy all have their advocates. After fracture of the subchondral bone plate has occurred, there is evidence that grafts are unable to restore the strength of the necrotic area. Intertrochanteric osteotomy brings under the main load-bearing zone a vital part of the femoral head. Varus osteotomy can be successful if necrosis has spared sufficient of the lateral portion of the head. Rotation osteotomies, as proposed by Sugioka, are more radical and difficult operations. The published results are promising. Revascularisation of the weight-bearing area by pedicle grafts has been attempted, alone or in addition to osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Spontaneous fractures of the neck of the femur occurring in pregnancy in the absence of pregnancy osteoporosis

Case report on a patient suffering from spontaneous fractures of the neck of the femur which occured during her first pregnancy at the age of 23 in the left leg and during another pregnancy seven years later in the right leg. Both fractures occured during the eighth month of pregnancy. Special attention is drawn to the fact that local or general osteoporosis which, according to literature, should be obligatory for the occurence of spontaneous necrosis of the femoral head and/or fractures of the neck of the femur, could be demonstrated neither during the first nor the second pregnancy.