Femoral osteotomies for the treatment of avascular necrosis of the femoral head

Total Hip Arthroplasty in Patients Under 30 Years Who Have Osteonecrosis of the Femoral Head: Mean Follow-Up of More than 120 Months

BACKGROUND

Osteonecrosis of the femoral head (ONFH) primarily affects young adults, leading to femoral head collapse and secondary osteoarthritis. Treatments include joint-preserving surgery, which has been performed preferentially, especially for young adults, and joint arthroplasty, i.e., total hip arthroplasty (THA). Although advancements in implant materials have markedly improved performance, there are few data regarding implant survival and clinical outcomes in younger patients. This study aimed to assess long-term implant survival of more than 120 months and clinical outcomes in young ONFH patients undergoing primary THA.

METHODS

This retrospective single-center study assessed 99 joints in 66 ONFH patients who underwent primary THA between 1997 and 2019. Patients were categorized according to age at the time of THA: group A, aged less than 30 years (20 joints) and group B, aged 30 years or more (79 joints). The mean age was 43 years, and 36 patients were men. The mean follow-up duration was 128.1 months. Clinical and radiographic characteristics were compared.

RESULTS

The median Japanese Orthopaedic Association score at the final follow-up was 100 in both groups (P = 0.41). Major complications occurred in 13 joints: one in group A and 12 in group B (P = 0.46). Overall implant survival rate was 100% at 60 months, 98% at 120 months, and 94% at 180 months. When considering aseptic loosening as the endpoint, the 180-month survival rate was 100%. No significant differences in survival rate were found between the groups with either endpoint (P = 1.00, P = 0.67).

CONCLUSIONS

Our results showed THA was a safe, effective treatment for young ONFH patients, with demonstrated efficacy over 120 months. Advances in implants and revision techniques support THA as a viable treatment, even as an initial treatment for young ONFH patients. Future research should assess longer follow-up with larger cohorts and standardized surgical methods.

Modified femoral neck rotational osteotomy with supercapsular approach as hip preservation surgery technique for osteonecrosis of femoral head in young patient: A case report

INTRODUCTION

Osteonecrosis of Femoral Head (ONFH) is a debilitating condition with multiple contributory etiological factors that can lead to significant hip pain and disability. All attempts should be taken to save the joint and postpone or avoid the necessity for a total hip arthroplasty (THA), particularly in young and active individuals.

CASE PRESENTATION

A 21-year-old female with 5-year history of Systematic Lupus Erythematosus (SLE) and long-term use of corticosteroids presented with left hip pain and limping that worsening over the past two months. She had a Leg Length Discrepancy (LLD) of 1 cm. After radiological examination, she was diagnosed with left ONFH FICAT II-III ARCO stage 3. The measured Kerboul angle was 1800, indicating a medium necrotic area. We performed joint preservation surgery through Femoral Neck Rotational Osteotomy (FNRO) using Hip Supercapsular Approach. On a 3-month evaluation, the patient's pain improved significantly, and radiographic evaluation showed good healing of the osteotomy site.

DISCUSSION

FNRO is a joint preservation surgery technique that aims to improve vascularization by moving the area of necrosis away from the weight-bearing region. The Hip Supercapsular Approach was chosen due to numerous advantages, such as short incisions, preservation of blood supply to the femoral head, and clear visualization of both necrotic lesion and healthy bone and cartilage.

CONCLUSION

Modified FNRO with Hip Supercapsular approach may be a promising surgical procedure for young patients with ONFH. It yields favorable results in terms of pain alleviation, improvement in joint functionality, and radiological outcomes while maintaining a minimally invasive setting.

Did the COVID-19 Pandemic Coincide With an Increase in Osteonecrosis as Indication for Total Hip Arthroplasty in Older Patients?

BACKGROUND

Osteonecrosis of the femoral head is a common indication for total hip arthroplasty (THA). It is unclear to what extent the COVID-19 pandemic has impacted its incidence. Theoretically, the combination of microvascular thromboses and corticosteroid use in patients who have COVID-19 may increase the risk of osteonecrosis. We aimed to (1) assess recent osteonecrosis trends and (2) investigate if a history of COVID-19 diagnosis is associated with osteonecrosis.

METHODS

This retrospective cohort study utilized a large national database between 2016 and 2021. Osteonecrosis incidence in 2016 to 2019 was compared to 2020 to 2021. Secondly, utilizing a cohort from April 2020 through December 2021, we investigated whether a prior COVID-19 diagnosis was associated with osteonecrosis. For both comparisons, Chi-square tests were applied.

RESULTS

Among 1,127,796 THAs performed between 2016 and 2021, we found an osteonecrosis incidence of 1.6% (n = 5,812) in 2020 to 2021 compared to 1.4% (n = 10,974) in 2016 to 2019; P < .0001. Furthermore, using April 2020 to December 2021 data from 248,183 THAs, we found that osteonecrosis was more common among those who had a history of COVID-19 (3.9%; 130 of 3,313) compared to patients who had no COVID-19 history (3.0%; 7,266 of 244,870); P = .001).

CONCLUSION

Osteonecrosis incidence was higher in 2020 to 2021 compared to previous years and a previous COVID-19 diagnosis was associated with a greater likelihood of osteonecrosis. These findings suggest a role of the COVID-19 pandemic on an increased osteonecrosis incidence. Continued monitoring is necessary to fully understand the impact of the COVID-19 pandemic on THA care and outcomes.

The association between three-dimensional measurement of posterior tilt angle in impacted femoral neck fractures and osteonecrosis of the femoral head

BACKGROUND

Hollow screw internal fixation is commonly used in clinical treatment of impacted femoral neck fractures. Previous studies have demonstrated a correlation between the preoperative posterior tilt angle of the femoral head and failure of internal fixation, but there are fewer studies related to the occurrence of postoperative femoral head necrosis and the posterior tilt angle.

METHODS

To examine the relationship between three-dimensional posterior tilt angle measurements in affected femoral neck fractures and postoperative osteonecrosis of the femoral head and related risk variables. We retrospectively examined 130 Yantaishan Hospital patients with affected femoral neck fractures from 2019 to 2022. Three-dimensional reconstruction technology assessed the posterior tilt angle of the femoral head and separated patients into necrosis and non-necrosis groups based on postoperative femoral head necrosis. Univariate analysis compared clinical data between groups, and multivariate logistic regression analyzed risk variables for femoral head necrosis. Postoperative femoral head necrosis was predicted by posterior tilt angle using Receiver operating characteristic (ROC) curve analysis.

RESULTS

Out of 130 patients who were followed up for 16-68 months postoperatively, 20 developed femoral head necrosis. Multivariate logistic regression analysis indicated that the posterior tilt angle and reduction quality level C were risk factors for the occurrence of femoral head necrosis. The ROC curve analysis showed that the three-dimensional measurement of the posterior tilt angle had predictive value for postoperative femoral head necrosis, with a cut-off value of 20.6°.

CONCLUSIONS

These results suggest that, for patients with impacted femoral neck fractures, the posterior tilt angle and reduction quality level C are risk factors for femoral head necrosis following closed reduction and internal fixation surgery. Fracture patients with a posterior tilt angle ≥ 20.6°are more likely to experience postoperative femoral head necrosis.

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.

Microrna-206 induces hypoxic necrosis of femoral head by inhibiting VEGF/PI3K/AKT signaling pathway

The most common form of non-traumatic necrosis of the femoral head is anoxic necrosis of the femoral head, which is a metabolic disease, mainly involving young and middle-aged people. Apoptosis and its related signal regulation pathway play an important role in the occurrence and development of hypoxic necrosis of the femoral head. In order to investigate the possible pathological manifestations of miR-206 and VEGF/PI3K/AKT signal pathway genes and their interactions in hypoxic necrosis of the femoral head, this paper intended to systematically study the expression and regulation mechanism of miR-206 and VEGF/PI3K/AKT signal pathway genes. The interaction between miR-206 and VEGF/PI3K/AKT signaling pathway and its regulation on apoptosis, differentiation and proliferation of human osteoblast cell line hFOB1.19 (SV40 transfer of human osteoblasts) were studied by double luciferase reporter gene analysis, overexpression and inhibition of miR-206, and gene silencing of VEGF/PI3K/AKT signaling pathway. After 24 h and 48 h of intervention with MicroRNA 206 on osteoblasts, it was found that the fluorescence intensity of caspase-3 was higher than that of 0 h group (p < 0.05). This paper has provided an important research basis for the research of femoral head necrosis and the development of new diagnosis and therapeutic drugs for this kind of disease. It also has provided a reference for the further promotion of the chemotherapy drug delivery system.

Analysis of Factors Influencing Postoperative Femoral Head Collapse in Patients With Ficat I, II, and III Stages of Aseptic Necrosis of the Femoral Head

OBJECTIVE

To investigate the factors influencing postoperative femoral head collapse (FHC) in patients with Ficat I, II, and III stages of aseptic necrosis of the femoral head (ANFH).

METHODS

Retrospective analysis of 178 patients with ANFH admitted to our hospital from October 2018 to October 2021 was studied, and patients were categorized into the FHC group and no FHC group according to whether FHC occurred after surgery. The influencing factors causing postoperative FHC were analyzed by univariate and multifactor logistic regression.

RESULTS

In the collapsed group, there were statistically significant differences in etiology, extent of necrosis, mechanism of injury, preoperative waiting time, Japanese Femoral Necrosis Research Society staging, distance from the tip of the tantalum rod to the center of necrosis, and Harris score after treatment ( P < 0.05). The etiology, extent of necrosis, mechanism of injury, preoperative waiting time, Japanese Femoral Osteonecrosis Research Society classification, distance between the tantalum rod tip and the center of necrosis, and Harris score after treatment were set as independent variables, and postoperative FHC in patients with Ficat I, II, and III stages of ANFH was used as the dependent variable in the univariate logistic regression analysis.

DISCUSSION

Hormonal osteonecrosis of the femur, extent of necrosis, type C1 and type C2 in the Japanese Society for the Study of Femoral Osteonecrosis staging, and distance of the tip of the tantalum rod from the center of necrosis are risk factors for postoperative FHC in patients with Ficat I, II, and III stages of ANFH.

Operative Management of Avascular Necrosis of the Femoral Head in Skeletally Immature Patients: A Systematic Review

Purpose: Osteonecrosis of the femoral head (ONFH) is common in skeletally immature patients. The management of ONFH is controversial, with limited evidence and unpredictable results. This study systematically reviewed the current operative modalities and clinical outcomes of surgical management for ONFH in skeletally immature patients. Methods: The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in October 2021. All the published clinical studies reporting data concerning the surgical management of ONFH in skeletally immature patients were included. Results: This review included 122 patients (127 hips). 38.2% (46 of 122) were female. The mean age of the patients was 14.2 ± 2.3 years. The mean duration of the follow-up was 55.3 ± 19.6 months. The Harris Hip Score improved from 68.8 ± 11.9 at baseline to 90.5 ± 6.5 at last follow-up (p < 0.0001). Femoral head collapse and secondary hip degeneration were the most common complications. Conclusion: Several surgical techniques are available and effective for the management of ONFH in skeletally immature patients. This study evidenced high heterogeneity of the surgical procedures and eligibility criteria. Further high-quality investigations are required to establish proper indications and surgical modalities.

Femoral cartilage damage occurs at the zone of femoral head necrosis and can be accurately detected on traction MR arthrography of the hip in patients undergoing joint preserving hip surgery

The primary purpose was to answer the following question: What is the location and pattern of necrosis and associated chondrolabral lesions and can they be accurately detected on traction MR arthrography compared with intra-operative findings in patients undergoing hip preservation surgery for femoral head necrosis (FHN)? Retrospective, diagnostic case series on 23 patients (23 hips; mean age 29 ± 6 years) with diagnosis of FHN undergoing open/arthroscopic joint preserving surgery for FHN and pre-operative traction MR arthrography of the hip. A MR-compatible device for weight-adapted application of leg traction (15-23 kg) was used and coronal, sagittal and radial images were acquired. Location and pattern of necrosis and chondrolabral lesions was assessed by two readers and compared with intra-operative findings to calculate diagnostic accuracy of traction MR arthrography. On MRI all 23 (100%) hips showed central FHN, most frequently antero-superiorly (22/23, 96%) where a high prevalence of femoral cartilage damage was detected (18/23, 78%), with delamination being the most common (16/23, 70%) damage pattern. Intra-operative inspection showed central femoral head cartilage damage most frequently located antero-superiorly (18/23, 78%) with femoral cartilage delamination being most common (14/23, 61%). Traction MR arthrography enabled detection of femoral cartilage damage with a sensitivity/specificity of 95%/75% for reader 1 and 89%/75% for reader 2. To conclude, femoral cartilage damage occurs at the zone of necrosis and can be accurately detected using traction MR arthrography of the hip which may be helpful for surgical decision making in young patients with FHN.

Versatile GCH Control Software for Correction of Loads Applied to Forearm Crutches During Gait Recovery Through Technological Feedback: Development and Implementation Study

Background

Measuring weight bearing is an essential aspect of clinical care for lower limb injuries such as sprains or meniscopathy surgeries. This care often involves the use of forearm crutches for partial loads progressing to full loads. Therefore, feasible methods of load monitoring for daily clinical use are needed.

Objective

The main objective of this study was to design an innovative multifunctional desktop load-measuring software that complements GCH System 2.0–instrumented forearm crutches and monitors the applied loads, displaying real-time graphical and numerical information, and enabling the correction of inaccuracies through feedback technology during assisted gait. The secondary objective was to perform a preliminary implementation trial.

Methods

The software was designed for indoor use (clinics/laboratories). This software translates the crutch sensor signal in millivolts into force units, records and analyzes data (10-80 Hz), and provides real-time effective curves of the loads exerted on crutches. It covers numerous types of extrinsic feedback, including visual, acoustic (verbal/beeps), concurrent, terminal, and descriptive feedback, and includes a clinical and research use database. An observational descriptive pilot study was performed with 10 healthy subjects experienced in bilateral assisted gait. The Wilcoxon matched-pairs signed-rank test was used to evaluate the load accuracy evolution of each subject (ie, changes in the loads exerted on crutches for each support) among various walks, which was interpreted at the 95% confidence level.

Results

GCH Control Software was developed as a multifunctional desktop tool complementing GCH System 2.0–instrumented forearm crutches. The pilot implementation of the feedback mechanism observed 96/100 load errors at baseline (walk 0, no feedback) with 7/10 subjects exhibiting crutch overloading. Errors ranged from 61.09% to 203.98%, demonstrating heterogeneity. The double-bar feedback found 54/100 errors in walk 1, 28/100 in walk 2, and 14/100 in walk 3. The first walk with double-bar feedback (walk 1) began with errors similar to the baseline walk, generally followed by attempts at correction. The Wilcoxon matched-pairs signed-rank test used to evaluate each subject’s progress showed that all participants steadily improved the accuracy of the loads applied to the crutches. In particular, Subject 9 required extra feedback with two single-bar walks to focus on the total load. The participants also corrected the load balance between crutches and fluency errors. Three subjects made one error of load balance and one subject made six fluctuation errors during the three double-bar walks. The latter subject performed additional feedback with two balance-bar walks to focus on the load balance.

Conclusions

GCH Control Software proved to be useful for monitoring the loads exerted on forearm crutches, providing a variety of feedback for correcting load accuracy, load balance between crutches, and fluency. The findings of the complementary implementation were satisfactory, although clinical trials with larger samples are needed to assess the efficacy of the different feedback mechanisms and to select the best alternatives in each case.