Combined pharmacotherapy for osteonecrosis of the femoral head after severe acute respiratory syndrome and interstitial pneumonia: two and a half to fourteen year follow-up

Insight into Steroid-Induced ONFH: The Molecular Mechanism and Function of Epigenetic Modification in Mesenchymal Stem Cells

Osteonecrosis of the femoral head (ONFH) is a common refractory orthopedic disease, which is one of the common causes of hip pain and dysfunction. ONFH has a very high disability rate, which is associated with a heavy burden to patients, families, and society. The pathogenesis of ONFH is not completely clear. At present, it is believed that it mainly includes coagulation dysfunction, abnormal lipid metabolism, an imbalance of osteogenic/adipogenic differentiation, and poor vascularization repair. The prevention and treatment of ONFH has always been a great challenge for clinical orthopedic surgeons. However, recent studies have emphasized that the use of mesenchymal stem cells (MSCs) to treat steroid-induced ONFH (SONFH) is a promising therapy. This review focuses on the role and molecular mechanism of epigenetic regulation in the progress of MSCs in the treatment of SONFH, and discusses the significance of the latest research in the treatment of SONFH from the perspective of epigenetics.

Evaluation of Radiographic Outcomes after Core Decompression for Osteonecrosis of the Femoral Head: The Beijing University of Chinese Medicine X-ray Evaluation Method

BACKGROUND

Joint-preserving treatments for osteonecrosis of the femoral head (ONFH) are an area of significant interest in orthopaedics as they may restore function and provide durable benefit to patients who would otherwise require early total hip arthroplasty. Studies reporting the outcomes for these procedures generally rely on a combination of radiographic and clinical outcomes. However, there is not currently a standardized radiographic scoring system that allows for objective reporting of radiographic outcomes following these procedures. This article introduces a novel scoring system (Beijing University of Chinese Medicine X-ray evaluation, BUCMXE) based on Anteroposterior (AP) hip radiographs to allow for objective evaluation and comparison of postoperative outcomes following joint-preserving treatments for ONFH.

METHODS

The proposed scoring system utilizes AP radiographs of the hip and consists of a total score (0-10) derived from the sum of subscores in 3 domains: femoral head morphology, osteonecrotic lesion, and degree of osteoarthritis. Each radiographic parameter is scored from 0 (normal) to 3 or 4 (advanced disease). The scoring model was retrospectively applied to a cohort of patients who had undergone core decompression and cancellous bone grafting procedures by the principal investigator.

RESULTS

The BUCMXE provided a clear and reproducible means of quantifying and communicating radiographic changes over the course of follow-up in our study cohort. Statistical analysis demonstrated that the BUCMXE was sensitive to detect the radiographic changes associated with the index procedure. The median total score was reduced from 3 preoperatively to 2 at the initial (3-month) follow-up for this cohort. This change was attributable to the obvious improvement of osteonecrotic lesion in patients who had more advanced disease at the time of their procedure.

CONCLUSION

The BUCMXE system allowed for objective quantification of radiographic changes following joint-preserving hip surgery in our cohort. Statistical analysis of BUCMXE scores demonstrated that the scoring system was sensitive to detect subtle radiographic changes associated with disease progression in the follow-up period.

LEVEL OF EVIDENCE

Therapeutic Level III.

Double Trouble-COVID-19 and the Widespread Use of Corticosteroids: Are We Staring at an Osteonecrosis Epidemic?

Background

A combination of immune-mediated vascular damage and routine use of systemic corticosteroid (CS) therapy in COVID-19 may significantly increase the risk and burden of osteonecrosis (ON) after COVID-19. This narrative review explores the pathogenesis, risk factors, and possible preventive and early treatment measures for ON in COVID-19.

Methods

For this narrative review, an extensive literature search was performed using the PubMed, Medline, and Science Direct databases from January 2000 to August 2021 for relevant articles on etiopathogenesis, epidemiology, clinical manifestations, and treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) infection and steroid-induced ON (SION).

Results

Pathogenesis of COVID-19, utility of corticosteroids in the treatment of COVID-19, pathogenesis of SION vis-a-vis SARS-CoV infection, associated risk factors, and early diagnosis and treatment of ON following CS therapy of SARS-CoV infection were discussed.

Conclusion

Preliminary data of COVID-19 and similar trends from the SARS 2003 epidemic indicate that the "angiocentric" pathogenesis of SARS-CoV-2 and treatment with high-dose CS may increase the risk of ON in COVID-19 patients. Risk stratification based on CS intake during COVID-19 treatment can help identify subjects at moderate to high-risk for ON where early preventive and follow-up plans can be initiated.

Global research trends of steroid-induced osteonecrosis of the femoral head: A 30-year bibliometric analysis

OBJECTIVE

To explore the global research trends and hotspots of steroid-induced osteonecrosis of the femoral head (SONFH) through qualitative and quantitative analysis of bibliometrics.

METHODS

All publications on SONFH published from 1992 to 2021 were extracted from the Web of Science Core Collection database. CiteSpace was used for the visualization analysis of major countries, active institutions, productive authors, and the burst of keywords. VOSviewer was used for coupling analysis of countries/regions, institutions, and authors. Microsoft Excel 2017 was used for statistical analysis, drawing bar charts, pie charts, and cumulative area charts. The software of MapInfo was used to draw the distribution map of the publications.

RESULTS

A total of 780 publications were included for analyses. The most productive year was 2020 with 98 records. China was the most influential country with 494 publications, an H-index of 59, and total citations of 16820. The most prolific institution was Shanghai Jiaotong University in China with 53 publications and 998 citations. Clinical Orthopaedics and Related Research (IF = 4.755, 2021) was the most active journal with 26 articles. The hot keywords were "osteonecrosis", "avascular necrosis", "osteogenic differentiation", "proliferation", "PPAR gamma", "apoptosis", "oxidative stress", "genetic polymorphism" and "mesenchymal stem cells". The keywords like "proliferation", "PPAR gamma" and "genome-wide" have emerged in recent years.

CONCLUSION

The number of publications in SONFH has increased significantly in the last three decades. The pathologic mechanism of SONFH gathered most research interests. Genomics and cell molecular biology of SONFH are the research frontiers.

[Clinical significance of different imaging manifestations of osteonecrosis of femoral head in the peri-collapse stage]

Objective

To explore the different imaging manifestations of osteonecrosis of the femoral head (ONFH) and their correlation with the occurrence of pain during the peri-collapse period.

Methods

The 372 patients (624 hips) with ONFH in the peri-collapse stage who were admitted between December 2016 and October 2019 and met the selection criteria were selected as the research objects. Among them, there were 270 males and 102 females, with an average age of 35.3 years (mean, 15-65 years). There were 120 cases of unilateral hip and 252 cases of bilateral hips. There were 39 cases (39 hips) of traumatic ONFH, 196 cases (346 hips) of hormonal ONFH, 102 cases (178 hips) of alcoholic ONFH, and 35 cases (61 hips) of idiopathic ONFH. Among them, there were 482 hips with pain symptoms and 142 hips without pain. The pain duration was less than 3 months in 212 hips, 3-6 months in 124 hips, 6-12 months in 117 hips, and more than 12 months in 29 hips. According to the Association Research Circulation Osseous (ARCO) staging, the ONFH was rated as stage Ⅱ in 325 hips and stage Ⅲ in 299 hips. The patients were grouped according to ONFH etiology and ARCO staging, and hip joint pain and X-ray film (crescent sign and cystic changes), CT (subchondral bone fractures and cystic changes), and MRI (bone marrow edema, joint effusion, and subchondral hypointensity zone) were compared. Spearman rank correlation was used to determine the correlation between ONFH pain duration and X-ray film, CT, and MRI imaging manifestations.

Results

There were significant differences ( P<0.05) between ONFH patients with different etiologies in crescent sign on X-ray film, subchondral bone fracture on CT, and joint effusion on MRI. And there were significant differences ( P<0.05) between ONFH patients with different ARCO stages in hip pain duration and all imaging manifestations. Correlation analysis showed that the pain duration of ONFH patients was correlated with all imaging manifestations ( P<0.05). The cystic change on CT was correlated with the subchondral hypointensity zone and joint effusion grade on MRI, and subchondral hypointensity zone and joint effusion grade on MRI were also correlated ( P<0.05).

Conclusion

The cystic changes, subchondral hypointensity zone, and joint effusion are closely related to the collapse of the femoral head and hip pain in patients with ONFH in the peri-collapse stage. The above-mentioned signals in stage Ⅱ ONFH indicate the instability of the femoral head, which is to predict the development of ONFH and the rational choice of hip-preserving treatment methods provides a basis.

Effects of hypoxia environment on osteonecrosis of the femoral head in Sprague-Dawley rats

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a disease in which the blood supply of the femoral head is interrupted or damaged, resulting in joint dysfunction. Hypoxic environments increase the expression of EPO, VEGF, and HIF causes vascular proliferation and increases the blood supply. It also causes the organism to be in a state of hypercoagulability and increases thrombosis. Therefore, the purpose of this study was to explore the occurrence of ONFH after the use of glucocorticoids (GCs) under conditions of hypoxia tolerance for a long time.

MATERIALS AND METHODS

Sprague-Dawley rats were fed in a hypobaric hypoxic chamber at an altitude of 4000 m, the whole blood viscosity, and plasma viscosity were determined to analyze the blood flow and hemagglutination. Western blotting, polymerase chain reaction, and immunohistochemistry were used to detect EPO, VEGF, CD31, and osteogenesis related proteins. Femoral head angiography was used to examine the local blood supply and micro-CT scanning was used to detect the structure of the bone trabecula.

RESULTS

Under hypoxic environments, the expression of EPO and VEGF increased, which increased the local blood supply of the femoral head, but due to more severe thrombosis, the local blood supply of the femoral head decreased.

CONCLUSIONS

Hypoxic environments can aggravate ONFH in SD rats; this aggravation may be related to the hypercoagulable state of the blood. We suggest that long-term hypoxia should be regarded as one of the risk factors of ONFH and we need to conduct a more extensive epidemiological investigation on the occurrence of ONFH in hypoxic populations.

Chinese herbal Huo-Gu formula for the treatment of steroid-associated osteonecrosis of femoral head: A 14-year follow-up of convalescent SARS patients

Purpose

The coronavirus disease 2019 (COVID-19) reminds us of the severe acute respiratory syndrome (SARS) outbreak in 2003, and up to date, corticosteroid is commonly administrated to severe patients with COVID-19. Osteonecrosis of the femoral head (ONFH) is a common disabling complication among convalescent SARS patients who received corticosteroid therapy. In China, a considerable number of convalescent SARS patients with steroid-associated ONFH had undergone conservative treatment by traditional Chinese medicine, and this study aims to evaluate the long-term results of a spleen-invigorating Huo-Gu formula (HGF) therapy in these patients.

Participants and methods

A total of 33 convalescent SARS patients (9 males and 24 females) with bilateral steroid-associated ONFH (66 hips) were enrolled in this study. All patients received oral HGF therapy for 6 months when they were confirmed the diagnosis of steroid-associated ONFH. They had been regularly followed up at an interval of 1 year. Harris hip score and medical imaging modalities, including plain radiography, computed tomography and magnetic resonance imaging, were performed to evaluate the outcomes.

Results

Based on average 14 years of follow-up of HGF therapy (ranging from 6 to 16 years), 38 hips (57%) among the 66 hips developed definite osteoarthritis, and 14 hips (26%) in 53 precollapse hips (Association Research Circulation Osseous [ARCO] Stage I or II) progressed to femoral head collapse (ARCO Stage III or IV). Only five patients (also 5 hips) underwent total hip arthroplasty, and the mean hip survival time was over 15 years by the Kaplan-Meier analysis. We observed a mean Harris hip score of 63 points, which represented the reserve of 55% in pain score and 70% in physical function score. The severity of groin pain was not correlated to the severity of osteoarthritis.

Conclusion

Chinese herbal HGF therapy demonstrates beneficial effects on preventing femoral head collapse, delaying total hip arthroplasty, and maintaining physical function in the treatment of steroid-associated ONFH. HGF therapy might be therefore a good alternative for the treatment of steroid-associated ONFH secondary to rheumatologic and infection diseases.

Translational potential of the article

HGF therapy might be a good alternative for the treatment of steroid-associated ONFH secondary to rheumatologic and infectious diseases.

Stem cell therapy in bilateral osteonecrosis: computer-assisted surgery versus conventional fluoroscopic technique on the contralateral side

PURPOSE

Surgical management of osteonecrosis with core decompression with stem cell therapy is a new procedure. The technique is performed with fluoroscopic guidance. This study attempts to determine if computer-navigated technique can improve the procedure.

METHODS

Thirty consecutive patients with bilateral symptomatic osteonecrosis without collapse were included in this study during the year 2011. A prospective, randomized, and controlled study was conducted on 60 hips (bilateral osteonecrosis) using conventional fluoroscopy technique on one side and computer-based navigation on the contralateral side. Bone marrow aspirated from the two iliac crests was mixed before concentration. Each side received the same volume of concentrated bone marrow and the same number of cells 110,000 ± 27,000 cells (counted as CFU-F).

RESULTS

Computer navigation achieved better parallelism to the ideal position of the trocar, with better trocar placement as regards to tip-to-subchondral distance and ideal centre position within the osteonecrosis for injection of stem cells. Using computer navigation took fewer attempts to position the trocar, used less fluoroscopy time, and decreased the radiation exposure as compared with surgery performed with conventional fluoroscopy. At the most recent follow-up (6 years), increasing the precision with computer navigation resulted in less collapse (7 versus 1) and better volume of repair (13.4 versus 8.2 cm³) for hips treated with the computer-assisted technique.

CONCLUSIONS

The findings of this study suggest that computer navigation may be safely used in a basic procedure for injection of stem cells.