Etiology of avascular osteonecrosis of the femoral head

Hip Arthroscopy Debridement Combined with Multiple Small-Diameter Fan-Shaped Low-Speed Drilling Decompression in the Treatment of Early and Middle Stage Osteonecrosis of the Femoral Head: 14 Years Follow-Up

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a disease that occurs frequently in young and middle-aged people. Because of its high disability rate, it affects the ability to work, so the early treatment of this disease is particularly important. This retrospective study aimed to evaluate the clinical efficacy of hip arthroscopy combined with multiple small-diameter fan-shaped low-speed drilling decompression (MSFLD) in treating early-mid stage ONFH (ARCO II-IIIA) compared to MSFLD, with at least 10-year follow-up.

METHODS

A total of 234 patients who underwent hip arthroscopy and MSFLD for ONFH from 1998 to 2012 were analyzed retrospectively. This study enrolled patients between 18 and 60 years old with ARCO stage II-III A, diagnosed clinically and through imaging, in accordance with the 2021 guidelines for the treatment of ONFH. Clinical data, including demographics, operation mode, BMI, pre- and postoperative Harris score, and femoral head survival rate, were collected. Patients were divided into hip arthroscopy + MSFLD and MSFLD groups based on the operation mode. The t-test was used to compare the postoperative efficacy, Harris scores, and survival rates of the femoral head between the two groups.

RESULTS

Among the 234 patients, 160 cases were followed up, including 92 cases in the hip arthroscopy + MSFLD group and 68 cases in MSFLD group, the follow-up rate was 68.38%, and the follow-up time was (10-22)14.11 ± 3.06 years. The Harris score (80.65 ± 6.29) in the hip arthroscopy + MSFLD group was significantly higher than that in the MSFLD group (p = 0.00), and the survival rate of femoral head (5-year survival rate was 84.78%, 10-year survival rate was 23.91%) was also higher than that in the MSFLD group (5-year survival rate was 63.24%, 10-year survival rate was 8.82%). The 5-year and 10-year survival rates of patients with ARCO II were 82.11% and 28.42%, which were better than 54% and 33% for ARCO III A. The femur head survival rate of alcoholic ONFH (5-year survival rate 61.54%, 10-year survival rate 9.23%) was significantly higher than that of other types of ONFH.

CONCLUSION

Clinical follow-up of at least 10 years suggests that hip arthroscopy combined with MSFLD is an effective treatment for early-mid stage ONFH, with good clinical effect and high survival rate of femoral head.

Analysis of the Potential Angiogenic Mechanisms of BuShenHuoXue Decoction against Osteonecrosis of the Femoral Head Based on Network Pharmacology and Experimental Validation

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a common orthopedic disease with a high disability rate. The clinical effect of BuShenHuoXue decoction (BSHX) for ONFH is satisfactory. We aimed to elucidate the potential angiogenic mechanisms of BSHX in a rat femoral osteonecrosis model and bone marrow mesenchymal stem cells (BMSCs).

METHODS

With in vivo experiments, we established the steroid-induced osteonecrosis of the femoral head (SONFH) model using Sprague-Dawley (SD) rats (8-week-old). The rats were randomly divided into five group of 12 rats each and given the corresponding interventions: control, model (gavaged with 0.9% saline), BSHX low-, medium- and high-dose groups (0.132 3, 0.264 6, and 0.529 2 g/mL BSHX solution by gavage). After 12 weeks, haematoxylin and eosin (H&E) staining was preformed to evaluate rat osteonecrosis. the expression of angiogenic factors (CD31, VEGFA, KDR, VWF) in rat femoral head was detected by immunohistochemistry, qPCR and western blotting. In cell experiment, BMSCs were isolated and cultured in the femoral bone marrow cavity of 4-week-old SD rats. BMSCs were randomly divided into eight groups and intervened with different doses of BSHX-containing serum and glucocorticoids: control group (CG); BSHX low-, medium-, and high-dose groups (CG + 0.661 5, 1.323, and 2.646 g/kg BSHX gavage rat serum); dexamethasone (Dex) group; and Dex + BSHX low-, medium-, and high-dose groups (Dex + 0.661 5, 1.323, and 2.646 g/kg BSHX gavaged rat serum), the effects of BSHX-containing serum on the angiogenic capacity of BMSCs were examined by qPCR and Western blotting. A co-culture system of rat aortic endothelial cells (RAOECs) and BMSCs was then established. Migration and angiogenesis of RAOECs were observed using angiogenesis and transwell assay. Identification of potential targets of BSHX against ONFH was obtained using network pharmacology.

RESULTS

BSHX upregulated the expression of CD31, VEGFA, KDR, and VWF in rat femoral head samples and BMSCs (p < 0.05, vs. control group or model group). Different concentrations of BSHX-containing serum significantly ameliorated the inhibition of CD31, VEGFA, KDR and VWF expression by high concentrations of Dex. BSHX-containing serum-induced BMSCs promoted the migration and angiogenesis of RAOECs, reversed to some extent the adverse effect of Dex on microangiogenesis in RAOECs, and increased the number of microangiogenic vessels. Furthermore, we identified VEGFA, COL1A1, COL3A1, and SPP1 as important targets of BSHX against ONFH.

CONCLUSION

BSHX upregulated the expression of angiogenic factors in the femoral head tissue of ONFH model rats and promoted the angiogenic capacity of rat RAOECs and BMSCs. This study provides an important basis for the use of BSHX for ONFH prevention and treatment.

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.

Mechanical properties of trabeculae and osteocyte morphology change significantly in different areas of the necrotic femoral head

Background: Osteonecrosis of the femoral head is a complex hip ailment. The precise changes in bone tissue during the disease's onset remain unclear. It is vital to assess both the quantity and quality of the trabecular state in a necrotic femoral head. Aim: This study aims to identify and compare the ultrastructural changes in osteocyte morphology and nanomechanical characteristics within various regions of necrotic femoral heads. Methods: Between December 2016 and May 2023, we gathered ten necrotic femoral heads from patients and five femoral heads from cadavers. The samples from the necrotic femoral heads were categorized into three areas: necrotic, sclerotic, and normal. Our assessment methods encompassed hematoxylin and eosin staining, sclerostin (SOST) immunohistochemistry, micro-computed tomography, nanoindentation, and acid-etched scanning electron microscopy. These techniques enabled us to examine the SOST expression, trabecular microstructure, micromechanical properties of trabeculae, and modifications in osteocyte morphology at the ultrastructural level. Results: The protein level of SOST was found to be lower in the sclerotic area. In the necrotic area, decreased values of bone volume fraction, trabecular thickness, and trabecular number and an increased value of trabecular separation were found. Conversely, in the sclerotic area, higher mean values of bone volume fraction, trabecular number, and trabecular thickness and lower trabecular separation indicated significant changes in the structural characteristics of trabeculae. Compared with the healthy area, the elastic modulus and hardness in the sclerotic area were significantly higher than those in the necrotic, normal, and control areas, while those in necrotic areas were significantly lower than those in the healthy area. The number of osteocytes tended to increase in the sclerotic area with more canalicular cells compared to the healthy area and control group. Conclusion: These results imply that the stress distribution within the sclerotic area could potentially lead to enhanced trabecular quality and quantity. This effect is also reflected in the increased count of osteocytes and their canaliculars. It is plausible that the sclerotic trabecular bone plays a pivotal role in the repair of necrotic femoral heads.

Osteonecrosis Related to Steroid and Alcohol Use-An Update on Pathogenesis

Osteonecrosis (ON) is usually a progressive disease that negatively affects the quality of life and leads to significant disability. Most patients are aged 30-50 years and require multiple surgical interventions throughout their lifetime. In non-traumatic ON, alcohol abuse and corticosteroids are involved in up to 80% of cases. This narrative review aims to summarize data on their impact on healthy bone and the development of pathophysiological processes leading to ON development. We conducted EMBASE and MEDLINE database reviews to identify relevant research. We found that for both agents, the risk was time and dose-dependent. ON in alcohol and steroid use shared many pathogenetic mechanisms leading to the development of necrosis, including increased adipogenesis, the induction of chronic inflammation, vascular alterations, and impaired bone-cell differentiation. Because both alcohol and steroid use are modifiable factors, both general physicians and orthopedic surgeons should encourage patients to limit ethanol intake and avoid corticosteroid overuse. In the presence of ON, because both alcohol- and steroid-induced disease tend to be multifocal, addiction treatment and limiting steroid use are justified.

Application of Biomaterials in Treating Early Osteonecrosis of the Femoral Head: Research Progress and Future Perspectives

Osteonecrosis of the femoral head (ONFH), a progressive pathological process of femoral head ischemia and osteocyte necrosis, is a refractory orthopedic disease caused by multiple etiologies and there is no complete cure at present. With the extension of ONFH duration, osteocyte apoptosis and trabecular bone loss can decrease the load-bearing capacity of the femoral head, which leads to the collapse of the articular cartilage and subchondral bone. Therefore, an urgent clinical need exists to develop effective treatment strategies of early-stage ONFH for maintaining the hip joint function and preventing femoral head collapse. In recent years, extensive attention has been paid to the application of diverse biomaterials in treating early ONFH for sustaining the normal morphology and function of the autologous femoral head, and slowing disease progression. Herein, we review the research progress of bone grafts, metallic materials, bioceramics, bioglasses and polymer materials for early ONFH treatment, and discuss the biological mechanisms of bone repair and regeneration in the femoral-head necrotic area. We propose suggestions for future research directions, from a special perspective of improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts (VAOs) generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts (BAOs) and BAO-mediated bone resorption. This review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH. STATEMENT OF SIGNIFICANCE: We believe that at least three aspects of this manuscript make it interesting to readers of the Acta Biomaterialia. First, we briefly summarize the incidence, pathogenesis, risk factors, classification criteria and treatment of early osteonecrosis of the femoral head (ONFH). Second, we review the research progress in biomaterials for early ONFH treatment and the biological mechanisms of bone repair and regeneration in femoral-head necrotic area. Third, we propose future research progress on improving the local microenvironment in femoral head by facilitating vessel-associated osteoclasts generation and coupling of bone-specific angiogenesis and osteogenesis, as well as inhibiting bone-associated osteoclasts and bone resorption. We hope this review can provide ideas for the research, development, and clinical application of biomaterials for treating early ONFH.

Intramedullary core decompression combined with endoscopic intracapsular decompression and debridement for pre-collapse non-traumatic osteonecrosis of the femoral head

BACKGROUND

The effect of core decompression on the treatment of pre-collapse non-traumatic osteonecrosis of the femoral head (ONFH) is still limited. This study aimed to explore the efficacy of core decompression combined with intra-articular decompression (debridement of the hip joint and incision of the hip capsule) under hip arthroscopic guidance in patients with pre-collapse ONFH.

METHODS

The clinical data of 101 patients with pre-collapse ONFH were analysed retrospectively. Sixty patients (80 hips) received small-diameter multi-channel core decompression alone in first half review period (group B). Forty-one patients (59 hips) were treated with small-diameter multi-channel core decompression combined with intra-articular decompression under hip arthroscopy guidance in second half review period (group A). The surgical duration; intraoperative bleeding; intra-articular pressure(IAP) before and after surgery; length of hospital stay; hospitalisation expenses; visual analogue scale (VAS) score before, 1 week, 4 weeks, 3 months and 1 year after surgery; and Harris score of the hip joint before, 3 months and 1 year after surgery were recorded and compared between group A and group B. X-ray examination was performed every month to observe the collapse of the femoral head within 2 years after surgery, which was compared using the Kaplan-Meier survival curve analysis.

RESULTS

When the two groups were compared, the surgical duration was longer and hospitalisation expenses were higher in group A than in group B (P < 0.05). However, the VAS score and the Harris score of the hip joint after surgery improved significantly compared with those before surgery (P < 0.05), which were more apparent in group A than in group B (P < 0.05). X-ray examination revealed that 6 hips in group A and 22 in group B received femoral head collapse at the 2-year follow-up. The survival rate of the femoral head in group A was significantly higher than that in group B (P < 0.05).

CONCLUSION

Small-diameter multi-channel core decompression combined with intra-articular decompression (debridement of the hip joint and incision of the hip capsule) under hip arthroscopic guidance for treating early ONFH can more effectively alleviate joint pain, improve joint function and delay ONFH progression.

Avascular Necrosis of Femoral Head-Overview and Current State of the Art

Avascular necrosis (AVN) of the femoral head is caused by disruption of the blood supply to the proximal femur. The alterations in the blood supply may occur following a traumatic event or result from a non-traumatic cause. Femoral neck fracture and hip dislocation and associated surgical procedures, corticosteroid therapy, and alcohol abuse frequently lead to AVN development. Type of fracture (displaced or undisplaced) and time between injury and surgery are the most critical factors in assessing the risk of developing AVN. Diagnosis of AVN can be established based on patients’ complaints, medical history, and radiographic findings. There is no consensus on the treatment of patients with AVN to date. Non-surgical methods are dedicated to patients in the early pre-collapse stages of the disease and consist of pharmacotherapy and physiotherapy. Surgery is recommended for patients with advanced disease.

IL-34 Aggravates Steroid-Induced Osteonecrosis of the Femoral Head via Promoting Osteoclast Differentiation

IL-34 can promote osteoclast differentiation and activation, which may contribute to steroid-induced osteonecrosis of the femoral head (ONFH). Animal model was constructed in both BALB/c and IL-34 deficient mice to detect the relative expression of inflammation cytokines. Micro-CT was utilized to reveal the internal structure. In vitro differentiated osteoclast was induced by culturing bone marrow-derived macrophages with IL-34 conditioned medium or M-CSF. The relative expression of pro-inflammation cytokines, osteoclast marker genes, and relevant pathways molecules was detected with quantitative real-time RT-PCR, ELISA, and Western blot. Up-regulated IL-34 expression could be detected in the serum of ONFH patients and femoral heads of ONFH mice. IL-34 deficient mice showed the resistance to ONFH induction with the up-regulated trabecular number, trabecular thickness, bone value fraction, and down-regulated trabecular separation. On the other hand, inflammatory cytokines, such as TNF-α, IFN-γ, IL-6, IL-12, IL-2, and IL-17A, showed diminished expression in IL-34 deficient ONFH induced mice. IL-34 alone or works in coordination with M-CSF to promote osteoclastogenesis and activate ERK, STAT3, and non-canonical NF-κB pathways. These data demonstrate that IL-34 can promote the differentiation of osteoclast through ERK, STAT3, and non-canonical NF-κB pathways to aggravate steroid-induced ONFH, and IL-34 can be considered as a treatment target.

Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis: a Bayesian network meta-analysis

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function.

AREAS OF CONTROVERSY

Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified.

GROWING POINTS

To provide an overview over current treatment options for ONFH compares their failure rates and conversion to total hip arthroplasty (THA) rates.

AREAS TIMELY FOR DEVELOPING RESEARCH

Core decompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.