Epidemiology of osteonecrosis among older adults in Sweden

Efficacy of synovectomy in the treatment of femoral head osteonecrosis with vascularised fibular grafting in Shanghai: a protocol for SYNERGY-VGF trial

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is characterised by progressive bone death, leading to joint incongruity and eventual osteoarthritis. Various interventions have been explored to forestall disease progression and delay total hip arthroplasty (THA). Free vascularised fibula grafting (FVFG) has shown promise, particularly in the precollapse stages of ONFH. However, the potential benefits of combining synovectomy with FVFG to address synovitis in ONFH have not been systematically studied. This trial seeks to compare outcomes between patients undergoing FVFG with and without synovectomy.

METHODS AND ANALYSIS

The trial is a randomised, single-centre, parallel-group trial comparing FVFG with synovectomy versus FVFG alone in patients with ONFH and synovitis. 90 participants will be randomised into two groups: synovectomy (n=45) and non-synovectomy (n=45). The primary outcome is the Harris Hip Score (HHS) change at 12 months post surgery. Secondary outcomes include HHS, Numeric Rating Scale (NRS) for pain, Depression Anxiety Stress Scales-21 (DASS-21), and EQ-5D scale assessments at intervals up to 12 months post randomisation.

ETHICS AND DISSEMINATION

This trial was approved by the Human Research Ethics Committee of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine prior to patient recruitment (approval number: 2023-076). Results from this trial will be published in peer-reviewed journals. Results will also be presented at international conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR) Identifier: ChiCTR2300073385. Prospectively registered on 10 July 2023.

Osteonecrosis: A disabling disease not to be ignored in asthma and atopic conditions

Osteonecrosis, also referred to as avascular necrosis, is a disease characterized by necrosis or death of a bone secondary to impairment in blood supply. The condition affects the epiphyseal ends of the bones such as the femur and the humerus, but it can also involve the metacarpal and metatarsal bones, the patella, the knee, the vertebrae, and the jaw. A plethora of inflammatory, autoimmune, hematological, thrombotic, and vascular diseases can lead to osteonecrosis. Corticosteroids are intimately linked to the development of osteonecrosis. The frequent use of systemic corticosteroids in patients with asthma, eczema, nasal polyposis, sinusitis, urticaria and angioedema, or anaphylaxis makes this disease of great relevance to the practicing allergist and pulmonologist. Untreated, bone necrosis leads to frustrated bone remodeling and angiogenesis, leading to subchondral fractures and collapse of the articular heads of the bones, and culminating in debilitating osteoarthritis, often requiring arthroplasty. Recent studies have shed light on the molecular mechanisms underlying osteonecrosis and on the role of glucocorticoids. The gold standard test in patients suspected of having the disease is magnetic resonance imaging scanning, with plain radiographs having a lower sensitivity and specificity. Early diagnosis and intervention are essential. The allergist should avoid the frequent use of glucocorticoids and consider early introduction of steroid-sparing alternatives for asthma or sinusitis. Smoking and alcohol ingestion need to be addressed, and the management of glucocorticoid-induced osteoporosis may be helpful. It is essential for allergists to familiarize themselves with the disease and its diagnosis and to consider early referral to an orthopedic surgeon for surgical intervention.

Advances in mechanism and management of bone homeostasis in osteonecrosis: a review article from basic to clinical applications

Osteonecrosis, characterized by bone cell death leading to impaired bone recovery, causes challenges in bone homeostasis maintenance. Bone homeostasis relies on the delicate balance between osteoclasts and osteoblasts, encompassing a series of complex and strictly regulated biological functions. Current treatments, including conservative therapies and surgeries, often fall short of expected outcomes, necessitating a reorientation towards more effective therapeutic strategies according to the pathogenesis. In this review, the authors hierarchically outlined risk factors, emerging mechanisms, and last-decade treatment approaches in osteonecrosis. By connecting mechanisms of bone homeostasis, the authors proposed future research directions should be focused on elucidating risk factors and key molecules, performing high-quality clinical trial, updating practice, and accelerating translational potential.

Multidimensional characteristics are associated with pain severity in osteonecrosis of the femoral head

Aims

Pain is the most frequent complaint associated with osteonecrosis of the femoral head (ONFH), but the factors contributing to such pain are poorly understood. This study explored diverse demographic, clinical, radiological, psychological, and neurophysiological factors for their potential contribution to pain in patients with ONFH.

Methods

This cross-sectional study was carried out according to the "STrengthening the Reporting of OBservational studies in Epidemiology" statement. Data on 19 variables were collected at a single timepoint from 250 patients with ONFH who were treated at our medical centre between July and December 2023 using validated instruments or, in the case of hip pain, a numerical rating scale. Factors associated with pain severity were identified using hierarchical multifactor linear regression.

Results

Regression identified the following characteristics as independently associated with higher pain score, after adjustment for potential confounders: Association Research Circulation Osseous classification stage IIIa or IIIb, bone marrow oedema, grade 3 joint effusion, as well as higher scores on pain catastrophizing, anxiety, and central sensitization. The final model explained 69.7% of observed variance in pain scores, of which clinical and radiological factors explained 37%, while psychological and neurophysiological factors explained 24% and demographic factors explained 8.7%.

Conclusion

Multidimensional characteristics jointly contribute to the severity of pain associated with ONFH. These findings highlight the need to comprehensively identify potential contributors to pain, and to personalize management and treatment accordingly.

Plasma SQSTM1/p62 act as a biomarker for steroid-induced osteonecrosis of the femoral head

Autophagy is closely associated with the onset and progression of steroid-induced osteonecrosis of the femoral head (SIONFH). SQSTM1/p62 is an important indicator of autophagic activity. The aim of this study was to investigate the role of SQSTM1/p62 in the development of SIONFH. From May 2021 through November 2021, 36 patients diagnosed with SIONFH and 36 healthy controls were recruited for this study. Evaluations included imaging and pathologic assessment of clinical bone tissue, location and level of SQSTM1/p62 expression, plasma SQSTM1/p62 levels, and receiver operating characteristic (ROC) curves. We observed that the expression level of SQSTM1/p62 in bone samples decreased with the Association Research Circulation Osseous (ARCO) phase. Plasma SQSTM1/p62 levels were significantly higher in the SIONFH group compared to healthy controls. Plasma SQSTM1/p62 levels were higher in pre-crash patients than in post-crash patients, and lower plasma SQSTM1/p62 levels were associated with elevated ARCO stage. Plasma SQSTM1/p62 may represent a potential biomarker for different stages during SIONFH. Lower plasma SQSTM1/p62 levels indicate an advanced stage of SIONFH. This study provides new clues for early diagnosis of SIONFH.

Oral Corticosteroids for Skin Disease in the Older Population: Minimizing Potential Adverse Effects

Corticosteroids play a crucial role as anti-inflammatory and immunomodulatory agents in dermatology and other medical specialties; however, their therapeutic benefits are accompanied by significant risks, especially in older adults. This review examines the broad spectrum of adverse effects (AEs) associated with oral corticosteroid therapy and offers strategies to prevent, monitor, and manage these issues effectively in older adults. AEs associated with systemic corticosteroids include immune suppression, gastrointestinal problems, hyperglycemia, insulin resistance, weight gain, cardiovascular complications, ocular issues, osteoporosis, osteonecrosis, muscle weakness, collagen impairment, psychiatric symptoms, and adrenal suppression. To minimize these AEs, tailored dosing and duration, frequent monitoring, and additional preventative measures can be employed to optimize corticosteroid treatment. By customizing management plans to the specific needs and risk factors associated with each patient, clinicians can promote the safe and effective use of oral corticosteroids, ultimately improving outcomes and quality of life in patients with inflammatory dermatologic disorders.

Osteonecrosis of acetabulum following total hip arthroplasty: A case report and literature review

Key Clinical Message

Despite being rare, we have presented a case of osteonecrosis of acetabulum that followed total hip arthroplasty. It's crucial to act appropriately, as it emulates periprosthetic joint infection. The key point is that the osteonecrosis of acetabulum may necessitate revision and can be classified as aseptic loosening.

Abstract

Osteonecrosis of the femoral head is well known and managed with total hip arthroplasty (THA). Acetabulum osteonecrosis can be classified as a cause of painful THA and the cemented acetabular component is a feasible option. However, it seems that the osteonecrosis of acetabulum is sparsely alluded in literature. In this case report sustaining of the right hip pain following THA of 35-year-old woman is discussed.

Effect of Patient Age on Total Hip Arthroplasty Outcomes in Patients Who Have Osteonecrosis of the Femoral Head Compared to Patients Who Have Hip Osteoarthritis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) affects both young and old patients. However, outcomes following total hip arthroplasty (THA) for these patients may vary with age. This study aimed to examine the effect of age on THA outcomes for non-traumatic ONFH patients, an area currently lacking research.

METHODS

Patients who had non-traumatic ONFH undergoing THA with at least 2 years of follow-up were identified using a database and divided into four groups by age. Then, 4 matched control groups of patients who had hip osteoarthritis (OA) were created. Multivariate logistic regression analyses were used to evaluate the rates of medical and surgical complications. Additionally, cohorts with a minimum 5-year follow-up were filtered to obtain further data on surgical outcomes. The study analyzed 85,462 non-traumatic ONFH and 80,120 hip OA patients undergoing THA.

RESULTS

Multiple medical complications in ONFH patients increased with age. Periprosthetic fracture within 2 years increased with age, while 90-day wound complications, 2-year periprosthetic joint infections, dislocations, and revisions decreased. The trends for complications continued at the 5-year follow-up. Compared to OA patients, those who had ONFH had higher risks of most complications, but this discrepancy decreased with age.

CONCLUSIONS

In ONFH patients undergoing THA, medical complications generally rise with age, while most surgical complications, including revisions, decrease. It is notable that ONFH patients experienced more complications than those who had OA, but this difference diminished with age.

A Comparative Analysis of Osteochondritis Dissecans and Avascular Necrosis: A Comprehensive Review

Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients' quality of life with pain, limited mobility, and dysfunction. OCD, involving cartilage and bone detachment in joints, predominantly affects young athletes, but its exact etiology and optimal management remain subjects of ongoing research. Conversely, AVN, marked by bone tissue death due to compromised blood supply, is linked to systemic factors like corticosteroid use and traumatic injuries. Diagnosis for both conditions relies on radiography and magnetic resonance imaging. Conservative treatment for AVN includes the use of a cane or crutches, pharmacological therapy, or physical therapy. On the other hand, in OCD, the primary approach is activity/sports restriction. Surgical treatment options for AVN patients encompass core decompression, bone grafting, or, in the most advanced cases, total hip arthroplasty. OCD may be surgically treated through subchondral drilling or fixation of unstable lesions. Advanced cases of OCD involve cartilage salvage with resurfacing techniques. The presentation of differences between these conditions enhances our understanding, facilitating improved diagnosis and management strategies.

Relative frequency of avascular necrosis of the hip as indication for primary Total Hip Arthroplasty in the USA vs. India

Introduction

Background: Primary total hip arthroplasty (THA) is performed for a variety of pathologies. Osteoarthritis (OA) is the most common indication for THA in the United States of America (USA). The study aims to establish the incidence of indications for THA in the USA as compared to India and to assess whether Avascular Necrosis (AVN) of the Hip is a more frequent indication for THA in India than in the USA.

Methods

The National Inpatient Sample database (USA) and two Indian databases (one national and one regional) were analyzed to identify all patients who underwent primary THA within the databases. The relative frequencies of each indication for THA were determined. The patients' demographics and risk factors for AVN of the hip were recorded and assessed. The data were then compared across the patients in the USA and the patients in India.

Results

225,061 primary THA patients were identified in the USA database and 20,288 in the Indian database. The proportion of primary THA performed for AVN in the American database (5.97%) was significantly lower than the proportion of THA performed for AVN in the Indian database (51.8%).

Conclusion

The relative frequency of AVN as an indication for THA is significantly higher in India than in the USA. It is important to recognize the differences in relative indications for THA between world populations, as outcomes after THA among Eastern populations of the world may not be equivalent to ones seen in their Western counterparts.

Intraosseous Tibial Resuscitation After a Total Knee Arthroplasty Leading to Osteonecrosis and Loosening of the Tibial Component

A 51-year-old woman suffered cardiac arrest requiring emergent intraosseous access that abutted the tibial component of her total knee arthroplasty. She developed a wound at the site and knee pain which was concerning for deep infection. Subsequent imaging was consistent with osteonecrosis developing around the tibial component. The component eventually loosened, requiring a revision surgery. Her deep cultures remained negative throughout. Her findings are most consistent with osteonecrosis and aseptic loosening of her prosthesis. While intraosseous access may be beneficial during resuscitation, it has complications. This is the first reported case of osteonecrosis secondary to intraosseous access leading to prosthetic loosening necessitating a revision surgery.

Avascular necrosis of the epiphyses of bones in patients who have had SARS-CoV-2 infection: Clinical observations and a narrative review of literature data

The SARS-CoV-2 coronavirus pandemic is a leading medical problem that is in the focus of attention of representatives of all medical specialties. In addition to fighting the COVID-19 infection itself, the task of preventing and treating a wide range of complications arising after the disease is becoming increasingly urgent. One of these complications is avascular necrosis (AN) of bone tissue – a severe pathology that leads to serious suffering, a decrease in the quality of life and disability of patients. For the period from 2020 to 2022 there are 9 reviews in the world literature devoted to the pathogenesis, clinical features and treatment possibilities of this complication. During the same period, 5 articles were published describing clinical observations of AN after suffering COVID-19.The purpose of this work is to demonstrate our own clinical observations, as well as to review the available literature data on the problem of AN after COVID-19 infection. Based on the analysis, it can be concluded that AN after SARS-CoV-2 infection most often develops in the femoral head (>50% of cases), occurs regardless of the severity of the disease and the cumulative dose of glucocorticoids used in the acute period of the disease. It seems advisable to perform an MRI of the hip joints at least once every 3 months for all patients who have had COVID-19 in severe and moderate form during the first year after convalescence.

Relative frequency of primary total hip arthroplasty for avascular necrosis in the United States as compared to a regional center: A data review

Background

The relative frequencies of indications for primary total hip arthroplasty (THA) are not well-established. This study aims to establish the incidence of THA performed for Avascular Necrosis of the hip (AVN), as well as the other most common indications for THA in the United States, as compared to the incidences at a high-volume tertiary referral center in Miami, Florida. We hypothesize that the relative incidence of AVN and each other indication for THA will vary significantly between the United States as a whole and the tertiary referral center.

Methods

A query of the 2016-2017 National Inpatient Sample (NIS) and a tertiary referral center adult reconstruction registry was completed. The relative frequencies of each indication for THA, demographics, and behavioral risk factors were analyzed.

Results

225,061 primary THA patients in the National Inpatient Sample database and 447 in the Miami tertiary referral center database were included in the final analysis. The proportion of primary THA for AVN in the NIS database (5.97%) was significantly lower than the same proportion in the tertiary referral center database (22.2%), p < .001. There was no significant difference in the incidence of primary THA for osteoarthritis, inflammatory arthritis, or hip dysplasia between the two populations.

Conclusion

The incidence of THA for AVN is significantly different between a tertiary referral center and the greater United States. Patient demographics, race, and behavioral risk factors are associated with the disparity. Orthopaedic surgeons should recognize the differences in THA indication between populations when counseling patients on treatments, outcomes, and the most current literature.

Steroid-induced osteonecrosis

Osteonecrosis associated with the use of glucocorticoids is a severe, potentially debilitating complication. In broader terms, it commonly involves the femoral head with secondary hip osteoarthritis. Osteonecrosis can also be caused by trauma and other non-traumatic factors besides steroid treatment. Nonetheless, glucocorticoid use is frequently observed in clinical settings in which this represents a common therapeutic option, including general practice, rheumatology and clinical immunology, among others. The pathogenesis involves genetic components, vascular impairment, adipocyte hypertrophy, and increased intraosseous pressure, ultimately leading to marrow and bone ischemia and necrosis and the process rapidly becomes irreversible. Osteonecrosis manifests with pain and impaired motility while the diagnosis is usually made with magnetic resonance imaging allowing early detection and potentially (dependent on the patient's needs for steroids and stage) timely management with conservative options, followed by joint replacement at late stages. In this review we discuss the pathogenesis, risk factors, diagnosis, staging, and management of this complication associated with glucocorticoid treatment.

Cementless femoral neck endoprosthesis SPIRON in men in aspects of clinical status and quality of life in an average 7-year follow-up

Background

We report the clinical evaluation, quality of life and pain assessment in patients who had a femoral neck SPIRON endoprosthesis.

Methods

The study group consisted of 27 men in whom 35 femoral neck endoprosthesis were implanted (8 on the left side, 12 on the right side and 7 bilateral) due to idiopathic osteoarthritis of the hip (20 patients) or avascular femoral osteonecrosis (7 patients) in a mean 7-year follow-up.

Results

The median pre-operative Harris Hip score (HHS) was 35.5 and post-operative 98.5 (p < 0.001). The median WOMAC HIP score was pre-operatively 57 and post-operatively 0 (p < 0.001). The median SF-12 score was pre-operatively 4 and post-operatively 33 (p < 0.001). The median pain assessment in VAS scale was 7 pre-operatively and 0 post-operatively (p < 0.001).

Conclusions

The results of all examined patients have changed significantly in every category showing that SPIRON endoprosthesis improved their quality of life and statistically reduced pain ailments. Moreover we have proved that higher BMI (> 30) is associated with worse operation outcomes.

[Drug-induced osteopathy in rheumatology]

Osteopathy in rheumatology can either be primary a condition as a consequence of inflammatory rheumatic diseases but can also be drug induced. The most severe clinical manifestations are insufficiency fractures and osteonecrosis. The risk of fractures is highest for patients treated with glucocorticoids depending on the daily intake, the cumulative glucocorticoid dosage and the duration of administration. An incidence rate of nearly 13% was reported after administration of glucocorticoids lasting > 1 year. Cases of osteonecrosis under glucocorticoids are, in contrast, less frequent and not associated with glucocorticoid-induced osteoporosis. The antiresorptive substances bisphosphonates and denosumab, as well as romosumab are effective and important in treating osteoporosis; however, they can also cause atypical fractures, particularly of the femur as well as osteonecrosis of the jawbone. According to the most recent guidelines the benefits of bisphosphonate treatment have only been verified for 3-5 years and for denosumab for 3 years. There are clear preventive recommendations to avoid osteonecrosis of the jaw. Ultimately, the disease-modifying antirheumatic drugs (DMARD) methotrexate and leflunomide also affect the metabolism of bones. There is a rare but very characteristic form of osteopathy associated with methotrexate, mainly occurring in cases of long-term treatment. The typical manifestations are insufficiency fractures, particularly of the distal tibia, which persist for many years under continuous methotrexate administration. The treatment is the discontinuation of methotrexate and in most cases the fractures will heal within 3-4 months. Leflunomide has been associated with cases of persisting pseudarthrosis that only disappeared after a wash-out of the active metabolite.

The Emerging Role of MicroRNAs in Bone Diseases and Their Therapeutic Potential

MicroRNAs (miRNAs) are a class of small (20-24 nucleotides), highly conserved, non-coding RNA molecules whose main function is the post-transcriptional regulation of gene expression through sequence-specific manners, such as mRNA degradation or translational repression. Since these key regulatory molecules are implicated in several biological processes, their altered expression affects the preservation of cellular homeostasis and leads to the development of a wide range of pathologies. Over the last few years, relevant investigations have elucidated that miRNAs participate in different stages of bone growth and development. Moreover, the abnormal expression of these RNA molecules in bone cells and tissues has been significantly associated with the progression of numerous bone diseases, including osteoporosis, osteosarcoma, osteonecrosis and bone metastasis, among others. In fact, miRNAs regulate multiple pathological mechanisms, including altering either osteogenic or osteoblast differentiation, metastasis, osteosarcoma cell proliferation, and bone loss. Therefore, in this present review, aiming to impulse the research arena of the biological implications of miRNA transcriptome in bone diseases and to explore their potentiality as a theragnostic target, we summarize the recent findings associated with the clinical significance of miRNAs in these ailments.

Glucocorticoid-induced osteonecrosis in systemic lupus erythematosus patients

Osteonecrosis (ON) is a complex and multifactorial complication of systemic lupus erythematosus (SLE). ON is a devastating condition that causes severe pain and compromises the quality of life. The prevalence of ON in SLE patients is variable, ranging from 1.7% to 52%. However, the pathophysiology and risk factors for ON in patients with SLE have not yet been fully determined. Several mechanisms for SLE patients' propensity to develop ON have been proposed. Glucocorticoid is a widely used therapeutic option for SLE patients and high-dose glucocorticoid therapy in SLE patients is strongly associated with the development of ON. Although the hips and knees are the most commonly affected areas, it may be present at multiple anatomical locations. Clinically, ON often remains undetected until patients feel discomfort and pain at specific sites at which point the process of bone death is already advanced. However, strategies for prevention and options for treatment are limited. Here, we review the epidemiology, risk factors, diagnosis, and treatment options for glucocorticoid-induced ON, with a specific focus on patients with SLE.

Evidence-Supported HBO Therapy in Femoral Head Necrosis: A Systematic Review and Meta-Analysis

Although many studies have shown that hyperbaric oxygen (HBO) therapy can significantly improve symptoms and quality of life of patients affected by femoral head necrosis, this therapy is not worldwide approved yet. This meta-analysis was performed to evaluate its clinical effect. Relevant studies published before May 2020 were systematically searched using terms related to HBO and femoral head necrosis. Fixed and random-effects models were used to estimate the odds ratio (OR) with 95% confidence intervals (CI). Subgroup analyses and publication bias tests were carried out to explore potential study heterogeneity and bias. Ten studies involving 353 controls and 368 HBO-treated cases were included, most of which were conducted on Asian population. The clinical effect in the HBO therapy group was 3.84 times higher than in the control group (OR = 3.84, 95% CI (2.10, 7.02), p < 0.00001). Subgroup analyses showed that the clinical effect of HBO therapy was statistically significant in the Asian subpopulation which represented most of the subjects (OR = 3.53, 95% CI (1.87, 6.64), p < 0.00001), but not in the non-Asian subpopulation, probably because of insufficient numerosity (OR = 7.41, 95% CI (0.73, 75.71), p = 0.09). The results of this meta-analysis suggest that patients with femoral head necrosis treated with HBO therapy can achieve a significant clinical improvement.

Destructive Osteonecrosis of the Femoral Head After a Single Intra-Articular Corticosteroid Injection: A Report of Two Cases

INTRODUCTION

Accelerated femoral head avascular necrosis after a single dose intra-articular steroid injection is a rare pathology. Few cases were reported in the literature. Most cases were managed with total hip arthroplasty.

CASE PRESENTATION

In this study, we report two rare cases of destructive osteonecrosis of the femoral head. Both patients presented with hip osteoarthritis that failed nonoperative measures. A single intra-articular corticosteroid injection was administered for each patient. Both patients had femoral head destruction and significant resorption at 14 and 11 weeks, respectively. Septic arthritis was ruled out by blood tests and joint aspiration. Total hip arthroplasty (THA) was undertaken and histology reports confirmed the osteonecrosis. The postoperative follow-up was uneventful with satisfactory hip function.

DISCUSSION AND CONCLUSION

Destructive osteonecrosis of the femoral head is a rare catastrophic potential complication of intra-articular corticosteroid injection. Hence, physicians must consider this complication when counseling patients before an intra-articular corticosteroid hip injection.

Bone-Specific Drugs and Osteonecrosis of Sites Other Than the Jaw: A Nationwide Cohort Study

Bone-specific drugs (BSDs) increase the risk of osteonecrosis of the jaw (ONJ), but whether they increase the risk of osteonecrosis at other sites is not known. Two studies, a cohort study and a case-control study, were conducted using registry data on everyone who was residing in Sweden on December 31, 2005, and who was 50 years of age or older at the time (n = 3,523,912). In the cohort study, individuals prescribed a BSD during the period 2006-2017 (n = 217,387) were 1:1 matched with nonusers on birth year, sex, hip fracture status, and Swedish or foreign origin. In the case-control study, individuals diagnosed with osteonecrosis during 2006-2017 (n = 12,614) were 1:1 matched with individuals without a diagnosis of osteonecrosis on birth year, sex, and Swedish or foreign background. In the cohort study, osteonecrosis was diagnosed in 983 BSD users and 214 nonusers (adjusted hazard ratio [aHR] 4.02; 95% CI, 3.32-4.87), during a mean treatment time of 2.8 years. A similar association was observed in a subcohort where all individuals diagnosed with cancer (HR 4.82; 95% CI, 2.52-9.22). The greatest difference in incidence between BSD users and nonusers was observed in patients with a femoral neck fracture that was not treated with total hip arthroplasty or hemiarthroplasty (incidence rate difference, 77.8 cases per 10,000 person-years, p < .05). The risk of osteonecrosis was higher in users of denosumab (HR 1.93; 95% CI, 1.33-2.79) and users of zoledronic acid (HR 1.95; 95% CI, 1.31-2.91) than in users of other BSDs. The increased risk of osteonecrosis decreased after the end of therapy (p < .001 for time trend). The results were confirmed in the case-control study. In summary, use of BSDs, especially more potent BSDs, is associated with increased risk of osteonecrosis of sites other than the jaw. This increased risk decreases after the final dose of BSD. © 2020 American Society for Bone and Mineral Research.

Hip preserving surgery for avascular hip necrosis: does terminating exposure to known risk factors improve survival?

Introduction: Avascular necrosis of the hip is rarely detected in early pre-radiographic stages (Arlet-Ficat stages I and II) where conservative treatment would still be possible. Studies of risk factors were often merely descriptive. The aim of the present study was to make a retrospective assessment of treatment survival rate for conservative management of avascular hip necrosis according to whether exposure to avoidable risk factors is eliminated or not. The study hypothesis was that eliminating avoidable risk factors is effective and reduces the risk of failure, and hence of hip replacement. Material and method: A single-center retrospective study was performed for conservatively managed avascular hip necrosis. Thirty-seven consecutive hips in 34 patients underwent decompression drilling, with a minimum 3-year follow-up. Known risk factors for osteonecrosis were classified as avoidable or non-avoidable. Results were analyzed according to the elimination of avoidable risk factors. The main endpoint was survival, with failure defined as femoral head collapse and/or recourse to total hip replacement. Avoidable risk factors (corticosteroids, smoking, alcohol consumption, blood pressure elevation, hypercholesterolemia) persisted for 17 hips (45.9%) and were prevented for 15 (40.5%). Five patients (5 hips: 13.5%) did not show preoperatively identified risk factors. Groups were demographically comparable. Results: Mean follow-up was 7.5 ± 3.7 years (range, 3.1-16.0 years). At last follow-up, there was a significant difference in survival at cumulative 9-year follow-up between patients with no risk factors (100%), with risk factors eliminated (59.3%; 95% CI, 0.273-0.012), and with persisting risk factors (23.5%; 95% CI, 0.013-0.458) (p = 0.001). Discussion: No studies were found in the literature assessing the survival of hip preserving surgery according to persistence or elimination of known risk factors for osteonecrosis. Eliminating risk factors significantly improved the survival rate for conservative treatment of femoral head necrosis.

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

➢. Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. ➢. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. ➢. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. ➢. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. ➢. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.

Psychological distress and health-related quality of life in patients with bone marrow edema syndrome

BACKGROUND

The aim of the study was to investigate psychological distress and health-related quality of life (HrQoL) in patients with bone marrow edema syndrome (BMES) of the hip or knee joint.

METHODS

This retrospective study included patients with the diagnosis BMES treated in the period 2016-2017. As well as analyzing the epidemiological data (age, sex, vascular disease, hypertension, etc.), we used the Hospital Anxiety and Depression Scale (HADS) to document anxiety and depression and the five-level version of the EuroQol Group's EQ-5D instrument (EQ-5D-5L) to assess HrQoL and compared it to historical controls of the healthy population.

RESULTS

The study group comprised 56 patients (26 females, 30 males) with a mean age of 55.8 (range, 15-84) years. HADS: there was no difference between the study and control cohorts in the rates of anxiety (P=0.595) or depression (P=0.241). EQ-5D-5L: the HrQoL was significantly lower in the patients with BMES than in the healthy controls both for parameters of the EQ-5D-5L index and in the various age groups. No difference in HrQoL was seen between BMES of the hip and the knee or among the different radiological stages of BMES.

CONCLUSIONS

The patients with BMES displayed a clear reduction in HrQoL, but this was not associated with psychological distress with regard to significant anxiety and depression. Patients with BMES and a high score for anxiety and depression are at great risk of chronic pain, and we recommend they should receive psychological counseling.