Osteotomies for avascular necrosis of the femoral head

Elevated levels of β C-terminal telopeptide of type 1 collagen and N-terminal mid-fragment of osteocalcin in patients with non-traumatic osteonecrosis of the femoral head

OBJECTIVE

To investigate the role of serum β C-terminal telopeptide of type 1 collagen (β-CTx) and N-terminal mid-fragment of osteocalcin (N-MID) concentration in non-traumatic osteonecrosis of the femoral head (NONFH).

MATERIALS AND METHODS

In this retrospective case-control study, serum β-CTx and N-MID levels were measured in 64 NONFH patients and 64 healthy controls. Propensity score matching (PSM) was used to balance the baseline characteristics of the two groups. The study was conducted at Linyi People's Hospital between January 2023 and February 2024. The primary outcomes included the differences in serum β-CTx and N-MID levels between the two groups, their correlations with clinical parameters, and their diagnostic performance for NONFH.

RESULTS

The serum concentration of β-CTx and N-MID was significantly higher in NONFH patients compared to healthy controls (β-CTx: 0.70 ± 0.30 ng/ml vs. 0.36 ± 0.16 ng/ml, P < 0.001; N-MID: 21.35 ± 8.24 ng/ml vs. 13.27 ± 3.87 ng/ml, P < 0.001). No significant differences were observed in serum β-CTx and N-MID levels among different etiological subgroups or ARCO stages. Pearson analysis revealed a positive correlation between serum β-CTx and N-MID levels, as well as β-CTx and pain duration. The ROC curve analysis showed that β-CTx had an AUC of 0.876 (95% CI 0.815-0.938) with a cut-off value of 0.505 ng/ml, sensitivity of 90.63%, and specificity of 76.56%. N-MID had an AUC of 0.860 (95% CI 0.797-0.924) with a cut-off value of 17.050 ng/ml, sensitivity of 84.38%, and specificity of 78.13%.

CONCLUSION

Serum β-CTx and N-MID levels are significantly elevated in patients with NONFH and may serve as potential biomarkers for the diagnosis of NONFH. Further studies with larger sample sizes are needed to validate these findings and explore their clinical applications.

Decreased serum and local GPX4 and SLC7A11 expression correlates with disease severity in non-traumatic osteonecrosis of the femoral head

BACKGROUND

Ferroptosis is implicated in various musculoskeletal conditions, including non-traumatic osteonecrosis of the femoral head (NT-ONFH).

OBJECTIVE

The objective of this study was to explore the levels of two crucial proteins associated with ferroptosis, namely Glutathione peroxidase 4 (GPX4) and Solute Carrier Family 7 Member 11 (SLC7A11), in both serum and femoral head samples, and to correlate their expression levels with the clinical severity of NT-ONFH.

METHODS

The study included 136 NT-ONFH patients and an equal number of healthy controls. In addition, 68 subjects suffering from femoral neck fractures (FNF) were included in the study. The serum concentrations of GPX4 and SLC7A11 were quantified using the enzyme-linked immunosorbent assay. The GPX4 and SLC7A11 levels among tissue samples were identified through immunohistochemical staining, western blot analysis, and quantitative real-time polymerase chain reaction (qRT-PCR). The radiographic severity of the condition was evaluated utilizing the Association Research Circulation Osseous (ARCO) classification system, while the symptomatic severity was assessed utilizing the Visual Analogue Scale (VAS) alongside the Harris Hip Score (HHS).

RESULTS

Patients diagnosed with NT-ONFH had considerably reduced serum concentrations of GPX4 and SLC7A11 in comparison to individuals in the healthy control group. Negative correlations of serum GPX4 and SLC7A11 levels with the ARCO stages were observed. A total of 73 ONFH and 68 FNF patients underwent total hip replacement. The mRNA and protein levels of GPX4 and SLC7A11 were lower in the necrotic areas compared to the non-necrotic areas and FNF femoral head tissues. Subsequent Receiver operating characteristic (ROC) curve analysis suggested that the decreased levels of both serum and local GPX4 and SLC7A11 could serve as potential biomarkers for the progression of ONFH. Furthermore, serum and local GPX4 and SLC7A11 levels were found to be negatively linked to the VAS score but positively related to the HHS score.

CONCLUSION

The levels of GPX4 and SLC7A11, both in serum and at the local site, were inversely correlated with the progression of NT-ONFH. Targeting ferroptosis and its associated proteins through potential therapeutic interventions could be a viable strategy to mitigate the severity of NT-ONFH.

Closed Reduction and Spica Cast Immobilization in Patients Aged 18 Months and Older With Developmental Dysplasia of the Hip

OBJECTIVES

For children aged 18 months and above with developmental dysplasia of the hip (DDH), treatment typically involves open reduction and hip reconstruction surgery. However, there is limited literature evaluating the efficacy of closed reduction in this patient population. The purpose of this study was to investigate the clinical efficacy of closed reduction and spica cast immobilization treatment for children aged 18 months and above with DDH, as well as the incidence of avascular necrosis of the femoral head (ANFH) and their associated risk factors.

METHODS

We retrospectively reviewed all children aged 18 months and above undergoing closed reduction and spica cast immobilization for DDH in our institution from January 2014 to December 2020. We found 51 hips suffered from closed reduction failure and identified 51 hips with successful closed reduction that matched the hips in the failure group in terms of age (difference < 1 month), weight (difference < 2 kg), and same gender. For patients with bilateral DDH, we prioritized self-matching, pairing the failed side with the successfully treated side. Relevant clinical data were collected and compared between the two groups. Multiple analyses of risk factors for closed reduction failure and ANFH were conducted by logistic regression.

RESULTS

In all, 61 patients (102 hips) were included in our study, 2 boys and 59 girls. Compared with the success group, the failure group more commonly had a higher International Hip Dysplasia Institute (IHDI) classification (Type III: 23.53% vs. 15.69%; Type IV: 60.78% vs. 23.53%, p < 0.001), a higher preoperative acetabular index (AI) index (39.42 ± 5.50 vs. 34.03 ± 6.15, p < 0.001), and a higher preoperative migration percentage (MP) (0.81 ± 0.27 vs. 0.54 ± 0.36, p < 0.001). Adjusting for other factors, the IHDI classification Types III-IV was the independent factor associated with closed reduction failure. Compared with the IHDI classification Type I, the failure risk of Type III and Type IV was increased 16.87 and 52.13 times, respectively (p < 0.05). ANFH was observed in three patients (4 hips, 4/102, 3.92%). All cases of ANFH occurred in the closed reduction failure group. The higher preoperative MP was related to the ANFH occurrence significantly through the unilateral factor analysis (0.98 ± 0.05 vs. 0.66 ± 0.34, p < 0.001). Adjusting for other factors, we did not find any independent factor regarding the ANFH occurrence (p > 0.05).

CONCLUSIONS

For patients aged 18 months and above with DDH, an IHDI classification assessment is necessary before closed reduction and spica cast immobilization. For patients classified as IHDI classification Types III and IV, active consideration of open reduction is advisable.

Osteonecrosis of the femoral head in post-COVID-19 patients: a retrospective comparative study

BACKGROUND

The COVID-19 pandemic has claimed many lives and continues to impact individuals through post-COVID-19 conditions. Osteonecrosis of the femoral head (ONFH) is increasingly recognized as a major post-COVID-19 complication, yet most studies are limited to case reports and small series. This study aimed to evaluate COVID-19-related factors potentially contributing to ONFH development in post-COVID-19 patients.

METHODS

A retrospective analysis was conducted on 84 patients with ONFH and a confirmed history of COVID-19. Baseline characteristics were collected, and patients were categorized into the following groups for comparative analysis: (1) vaccinated vs. unvaccinated, (2) unilateral vs. bilateral ONFH, (3) dexamethasone (DEX) and methylprednisolone (MPS) vs. DEX therapy, and (4) Association Research Circulation Osseus (ARCO) stage 2 vs. stage 3. Group differences and associations were analyzed.

RESULTS

The DEX and MPS-treated group had a greater extent of COVID-19 lung involvement compared to the DEX-treated group (59.2% vs. 36.3%, p = 0.002), as well as longer hospital stays in both general ward (14.2 days vs. 10.6 days, p = 0.018) and ICU (5.4 days vs. 3 days, p = 0.017). The DEX and MPS-treated group also had a longer duration of steroid therapy (19.3 days vs. 12.3 days, p < 0.001) and received higher DEX-equivalent cumulative steroid doses (380 mg vs. 125 mg, p < 0.001). Notably, ONFH symptoms developed earlier in the DEX and MPS-treated group compared to the DEX-treated group (7.5 months vs. 12 months, p = 0.004). Multivariable logistic regression analysis identified cumulative steroid dose as the sole predictor of ONFH severity (OR: 1.015, 95% CI: 1.001-1.028, p = 0.032), with ARCO stage 3 patients receiving higher cumulative steroid doses than stage 2 patients (240 mg vs. 126 mg, p = 0.018).

CONCLUSIONS

Our study demonstrated that cumulative steroid dose is the primary determinant of ONFH severity in post-COVID-19 patients. Additionally, combined use of corticosteroids may accelerate the onset of ONFH, highlighting the need for cautious steroid management in COVID-19 patients.

Advancements in 3D printing technologies for personalized treatment of osteonecrosis of the femoral head

Three-dimensional (3D) printing technology has shown significant promise in the medical field, particularly in orthopedics, prosthetics, tissue engineering, and pharmaceutical preparations. This review focuses on the innovative application of 3D printing in addressing the challenges of osteonecrosis of the femoral head (ONFH). Unlike traditional hip replacement surgery, which is often suboptimal for younger patients, 3D printing offers precise localization of necrotic areas and the ability to create personalized implants. By integrating advanced biomaterials, this technology offers a promising strategy approach for early hip-preserving treatments. Additionally, 3D-printed bone tissue engineering scaffolds can mimic the natural bone environment, promoting bone regeneration and vascularization. In the future, the potential of 3D printing extends to combining with artificial intelligence for optimizing treatment plans, developing materials with enhanced bioactivity and compatibility, and translating these innovations from the laboratory to clinical practice. This review demonstrates how 3D printing technology uniquely addresses critical challenges in ONFH treatment, including insufficient vascularization, poor mechanical stability, and limited long-term success of conventional therapies. By introducing gradient porous scaffolds, bioactive material coatings, and AI-assisted design, this work outlines novel strategies to improve bone regeneration and personalized hip-preserving interventions. These advancements not only enhance treatment efficacy but also pave the way for translating laboratory findings into clinical applications.

Robot-Based Minimally Invasive Spherical Osteotomy System Improves the Accuracy and Reproducibility of the Resulting Surface

BACKGROUND

A minimally invasive spherical osteotomy assistant system (MISOS) based on a multi-axis surgical robot was designed to improve the control and precision of manual spherical osteotomy.

METHODS

Based on human sawbone models, the feasibility of MISOS was verified by comparing the osteotomy centre deviation and the section curvature of the acetabulum, femur, and tibia.

RESULTS

Compared with freehand spherical osteotomy, the MISOS system demonstrated superior centre deviation for the acetabulum (1.48 ± 0.93 vs. 11.15 ± 3.97 mm), femur (3.12 ± 0.75 vs. 8.81 ± 3.04 mm), and tibia (1.91 ± 0.84 vs. 7.33 ± 1.53 mm) as well as superior curvature deviation for the acetabulum (1.40 ± 0.08 vs. 3.16 ± 0.56 mm), femur (0.26 ± 0.07 vs. 0.491 ± 0.21 mm), and tibia (0.21 ± 0.02 vs. 0.46 ± 0.18 mm). These results indicate that MISOS can assist surgeons in performing accurate and stable spherical osteotomy.

CONCLUSION

The MISOS system demonstrates promise as a precise assistive tool for minimally invasive orthopaedic spherical osteotomy, with potential for broader clinical applications.

Fibroblast IRF7-mediated chondrocyte apoptosis affects the progression of collapse in steroid-induced osteonecrosis of the femoral head

PURPOSE

The objective of this study was to identify potential genes implicated in the "peri-collapse" synovium of osteonecrosis of the femoral head through coding gene sequencing and to further clarify their specific mechanisms via in vitro experiments.

METHODS

Steroid-induced osteonecrosis of the femoral head (SIONFH) (n = 3), femoral neck fracture (FNF) (n = 3), and hip osteoarthritis (HOA) (n = 3) Synovial tissue of the hip joint was collected in total hip arthroplasty. A cellular model of SIONFH constructed from rat synovial fibroblasts by lipopolysaccharide intervention. Lentiviral technology was used to construct a model for fibroblast knockout of the Irf7 gene. HE was used to compare the characteristics of synovial tissue damage, and immunofluorescence and immunohistochemistry were used to compare the expression levels of VIM, IRF7, and IFNα. PCR, WB, and IF were used to examine Irf7 knockdown efficiency, chondrocyte proliferation (Col2a1, Aggrecan, Sox9), cartilage matrix degradation (Mmp13), and apoptosis (Bcl2, Bax, and Caspase3) expression under co-culture conditions. Crystalline violet staining was used to observe the migration rate of fibroblasts, and flow cytometry was used to detect the apoptosis level of chondrocytes under co-culture conditions.

RESULTS

Transcriptome sequencing of synovial tissue and fibroblasts ultimately screened for six differential genes, HOOK1, RNPC3, KCNA3, CD48, IRF7, SAMD9. Compared to FNF and HOA, synovial inflammatory cell recruitment and synovial hyperplasia were more pronounced in SIONFH. IF and IHC confirmed high expression of IRF7 and IFNα in the synovium of SIONFH. PCR and WB results suggested that fibroblasts highly expressed Irf7, Hook1, Rnpc3, Kcna3, Cd48, Samd9, Il-6, and Tnfα after lipopolysaccharide intervention, and the expression levels of Il-6 and Tnfα were significantly reduced after knockdown of Irf7 (P < 0.001). In the co-culture system, fibroblasts intervened with lipopolysaccharide significantly promoted chondrocyte apoptosis, the rate of cartilage matrix degradation, while inhibiting the level of chondrocyte proliferation, and this result was significantly reversed in Irf7 knockout fibroblasts. This was supported by flow cytometry results.

CONCLUSIONS

IRF7, HOOK1, RNPC3, KCNA3, CD48, and SAMD9 as potential genes affecting the progression of SIONFH collapse. Irf7 mediates the fibroblast inflammatory response and affects the collapse process of SIONFH by influencing chondrocyte apoptosis. Thus, intervention in IRF7 holds promise as one of the key targets for reversing the collapse process of SIONFH.

Icariin promotes osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) by activating PI3K-AKT-UTX/EZH2 signaling in steroid-induced femoral head osteonecrosis

BACKGROUND

Differentiation of bone marrow mesenchymal stem cells (BMSCs) is pivotal in the pathogenesis of steroid-induced femoral head osteonecrosis. Icariin, an active ingredient in Epimedii herba, has the potential to regulate osteogenic differentiation of BMSCs. Nevertheless, the related mechanism is still unclear. The study aimed to explore whether icariin can affect osteogenic differentiation by activating PI3K/AKT signaling to alter UTX and EZH2 expression and thus regulating osteogenesis-related genes in BMSCs.

METHODS

BMSCs were collected from Sprague Dawley rats and identified by measuring the positive ratios of cell markers using flow cytometry. Cells were treated with 1 μmol/L dexamethasone (DEX) for 24 h with or without 0.1-10 μM of icariin treatment. Cell counting Kit-8 (CCK-8) assays and flow cytometry analyses were performed to measure cell viability and apoptosis. Western blotting was conducted for measurement of apoptotic markers, factors involved in the PI3K/AKT-UTX/EZH2 pathway, osteogenic markers, and adipogenesis-related factors. Alizarin red S staining and Oil-red O staining were performed to measure the effect of DEX, icariin, UTX overexpression, or EZH2 knockdown on osteogenic and adipogenic differentiation of BMSCs.

RESULTS

Icariin ameliorated DEX-induced rat BMSC injury. Icariin activated the PI3K/AKT signaling, thereby upregulating UTX and phosphorylated EZH2 levels while inhibiting EZH2 and H3K27me3 expression. Additionally, icariin promoted osteogenic differentiation and inhibited adipogenic differentiation of BMSCs. Importantly, overexpressing UTX or silencing EZH2 exerted similar effects on BMSC differentiation as icariin did.

CONCLUSIONS

Icariin promotes osteogenic differentiation of DEX-treated BMSCs by activating PI3K/AKT signaling to upregulate UTX and inhibit EZH2, finally inducing H3K27me3 depletion.

Bilateral same-day transtrochanteric rotational osteotomy using computed tomography-based navigation: a case report

BACKGROUND

Transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH) is considered technically demanding, with varying results among institutions. This is due to the complex soft tissue exposure and determination of the osteotomy line. We report a case in which the osteotomy line was assessed using the Stryker OrthoMap® three-dimensional (3D) computed tomography (CT)-based navigation system and determined as preoperatively planned.

CASE PRESENTATION

The patient was a 24-year-old male with alcohol-related ONFH. Japanese Investigation Committee Classification Type C2/C2 Stage 3b/3b was confirmed through magnetic resonance imaging, and TRO was performed bilaterally on the same day using the Stryker OrthoMap® 3D CT-based navigation system. The patient was hospitalized for 55 days, and full loading was allowed at 6 months postoperatively. Eight months after surgery, the patient could return to work at his previous job in the restaurant industry relatively quickly. One and a half years postoperatively, the functional score improved from a preoperative visual analog scale of 90 to 12 mm at and the Japanese Hip Society Hip Evaluation Questionnaire improved from 31 points preoperatively to 59 points.

CONCLUSIONS

This is the first report of a bilateral TRO for bilateral ONFH performed on the same day using CT-based navigation. For osteonecrosis, which is often bilateral, accurate determination of the osteotomy line as planned preoperatively using CT-based navigation contributes to shorter operative time, less intraoperative blood loss, and allows for bilateral same-day surgery. This may improve situations in which patients are hesitant to undergo bone-preserving surgery because of the long period of time required to return to work, thereby facilitating their early reintegration into society.

Relationship between anterior or posterior femoral head necrosis and collapse based on MRI-defined key necrotic layer sets

BACKGROUND

Current clinical studies on femoral head necrotic lesions primarily focus on the medial and lateral regions, while detailed MRI-based methods to evaluate the relationship between anterior or posterior necrosis and collapse remain lacking.

OBJECTIVE

By defining the anterior and posterior positions of the femoral head in MRI, a method was proposed for rapid clinical prognosis assessment of femoral head necrosis based on necrotic location.

METOHD

A retrospective analysis was conducted on TSE sequence T1W1 coronal plane images from 200 cases of femoral head necrosis. The frequency of necrotic lesions appearing on each MRI layer was statistically analyzed to construct a high-frequency necrotic layer set. Among these cases, 100 hips were randomly selected, and the relationship between femoral head collapse at one-year follow-up and different high-frequency necrotic layer sets was analyzed to identify the key necrotic layer set. Based on this, the anterior and posterior regions of the femoral head were defined on MRI. The remaining 100 hips were used as a validation set to assess the impact of anterior or posterior necrosis of the femoral head, as defined by this method, on collapse.

RESULTS

In this study, a total of eight high-frequency necrotic lesion layer sets (S1-S8) were constructed based on MRI data. Among them, S3 (L1 + L2 + L0 + L3) showed the strongest correlation with femoral head collapse, with an AUC of 0.662. Therefore, S3 was defined as the anterior side of the femoral head. Analysis of the validation set revealed that, using this method, the probability of femoral head collapse was 11.4 times higher when necrotic lesions appeared on the anterior side compared to the absence of necrosis on the anterior side.

CONCLUSION

In MRI, the anterior side of the femoral head corresponds to the S3 region, where necrosis increases the risk of collapse by 11.4 times.

Hip joint-preserving strategies for treating osteonecrosis of the femoral head: From nonoperative to operative procedures

Osteonecrosis of the femoral head (ONFH) has an exceedingly high prevalence and disability rate, causing a tremendous socioeconomic burden. The prevalence of ONFH is increasing, while the population of the patients with ONFH is becoming younger. Once the femoral head collapses, treatment becomes difficult and often requires a hip joint replacement, which is not favorable for young patients. Therefore, hip joint-preserving treatments at an early stage of ONFH are particularly important. This study provides a comprehensive review on hip-preserving strategies for treating ONFH, including nonoperative treatments (e.g., protective weight bearing, hyperbaric oxygen, pulsed electromagnetic, extracorporeal shockwave, bisphosphonate, anticoagulants, hypolipidemics, vasodilators, and traditional Chinese medicine) and operative treatments (e.g., core decompression, osteotomy, bone grafting, mesenchymal stem cell transplantation, tantalum rods, and tissue engineering). Nonoperative treatments aim to slow down the progression of the disease and delay the need for joint replacement; however, they usually cannot effectively prevent the progression of the disease, except in cases of small necrosis areas (<10 %). Additionally, nonoperative treatments have unclear mechanisms that require further investigation. In contrast, operative treatments may stop the negative outcomes of necrosis and therefore appear to be more promising. Currently, an emerging area in operative treatments is regenerative medicine, which could promote the generation of bone tissues and blood vessels and restore hip joint function to pre-necrotic levels as much as possible. This review seeks to not only provide an important reference for clinicians when choosing appropriate strategies for treating ONFH but also offer certain guidance for future basic research in developing ONFH treatments.

The translational potential of this article

The incidence of ONFH is increasing, and patients are becoming younger on average. Therefore, the development of hip joint-preserving strategies to treat ONFH at earlier stages is urgently needed, particularly for young patients. However, a comprehensive review is lacking regarding the currently-available hip joint-preserving strategies and their effectiveness. This study is motivated to fill this gap and serve as an important reference for clinicians in choosing appropriate strategies to treat ONFH.

Study on the mechanism of Shuanghe decoction against steroid-induced osteonecrosis of the femoral head: insights from network pharmacology, metabolomics, and gut microbiota

BACKGROUND

Steroid-induced osteonecrosis of the femoral head (SONFH) is a challenging and debilitating orthopedic condition with a rising incidence in recent years. Shuanghe Decoction (SHD), a traditional Chinese medicine formula, has shown significant efficacy in treating SONFH, though its underlying mechanisms remain unclear.

PURPOSE

This study aims to elucidate the therapeutic effects and potential mechanisms of SHD on SONFH through in vivo experiments, combined with network pharmacology, metabolomics, and gut microbiota analysis.

MATERIALS AND METHODS

Forty male Sprague-Dawley rats (300 ± 20 g) were randomly assigned to four groups: Control, Model, SHD-L, and SHD-H, with 10 rats each. SONFH was induced in all groups except the Control group using lipopolysaccharide and methylprednisolone. The SHD-L and SHD-H groups were treated with Shuanghe decoction at doses of 4.86 g/kg/day and 9.72 g/kg/day, respectively, for eight weeks. Bone morphology, pathological changes, and osteogenic factors were evaluated using Micro-CT, histological staining, and immunohistochemistry. Network pharmacology, metabolomics, and gut microbiota analyses were conducted to explore SHD's mechanisms.

RESULTS

SHD improved bone morphology and increased osteogenic factor expression (RUNX2, OCN, COL-I). Network pharmacology indicated that metabolic pathways play a key role in SHD's therapeutic effects. Metabolomic analysis identified 14 differential metabolites, including 21-hydroxypregnenolone and tyramine, which were restored to normal levels by SHD. Gut microbiota analysis revealed that SHD modulated bacterial abundance, particularly Verrucomicrobia, Allobaculum, and Burkholderiales. A comprehensive network identified two key metabolites (tyramine, 21-hydroxypregnenolone), seven targets (CYP19A1, CYP1A2, CYP1B1, CYP2C9, CYP3A4, MIF, and HSD11B1), two metabolic pathways (tyrosine metabolism, steroid hormone biosynthesis), and four bacterial taxa (Jeotgalicoccus, Clostridium, Corynebacterium, rc4-4) as central to SHD against SONFH.

CONCLUSION

SHD alleviates SONFH by reshaping gut microbiota, reversing metabolic imbalances, and enhancing osteogenesis. Our findings provide novel insights into the pharmacological mechanisms of SHD, laying a foundation for its clinical application in treating SONFH.

A nomogram for predicting contralateral femoral head collapse after unilateral replacement of bilateral femoral head necrosis

This study aimed to develop and validate a nomogram, which can effectively predict the risk of contralateral asymptomatic femoral head collapse in patients with bilateral osteonecrosis of the femoral head (ONFH), undergoing unilateral total hip arthroplasty (THA). We retrospectively analyzed the clinical data of patients who underwent unilateral THA for bilateral non-traumatic ONFH in our center from 2015 to 2018. A total of 103 patients participated in at least 5 years of follow-up. The patients were randomly divided into a training set (70%) and a validation set (30%). Univariate and multivariate Cox analyses were used to determine the independent risk factors for contralateral femoral head collapse. Based on these factors, a predictive nomogram model for 3, 4, and 5 years after THA was developed, and the model was evaluated using receiver operating characteristic (ROC) curve analysis, area under the curve (AUC), decision curve analysis (DCA), and calibration curves. Among the103 patients, 64 patients (62.1%) experienced contralateral femoral head collapse after surgery. Independent risk factors included Japanese investigation committee (JIC) types C1 and C2, lower limb length difference, CE angle, and Harris hip score (HHS) one month after the primary THA. The AUC, calibration curves, and DCA for the predictive model at 3, 4, and 5 years demonstrated good performance of the nomogram. The predictive nomogram model shows good accuracy and clinical utility. Using this tool, clinicians can accurately judge the collapse of the contralateral asymptomatic femoral head after unilateral THA in patients with bilateral ONFH, and they can formulate individualized treatment plans.

Association of serum and local GRP78 and CHOP expressions with disease progression in patients with non-traumatic osteonecrosis of femoral head

BACKGROUND

The endoplasmic reticulum stress (ER stress) has been involved in various musculoskeletal disorders including non-traumatic osteonecrosis of femoral head (NT-ONFH).

OBJECTIVE

The current study aimed to investigate the association of glucose-regulated protein 78 (GRP78) as well as CCAAT/enhancer-binding protein homologous protein (CHOP) expressions in serum and femoral head (FH) tissues with NT-ONFH's severity.

METHODS

We enrolled NT-ONFH patients (n = 150) alongside healthy controls (HCs, n = 150). Meanwhile, 49 patients with femoral neck fracture (FNF) were also enrolled. Serum CHOP and GRP78 levels were determined through enzyme linked immunosorbent assay (ELISA). Local CHOP and GRP78 expressions were detected by immunohistochemistry, western blot, alongside real-time polymerase chain reaction (RT-PCR). Radiographic severity was assessed by FICAT grading system. The visual analogue scale (VAS) together with Harris hip score (HHS) were utilized to determine symptomatic severity.

RESULTS

Serum CHOP and GRP78 levels were markedly increased in NT-ONFH patients than HCs. NT-ONFH patients at FICAT stage 4 showed significant higher serum CHOP and GRP78 levels in contrast with those at stage 3. Furthermore, patients at stage 3 demonstrated higher serum CHOP and GRP78 levels than those at stage 2. There was a positive correlation observed between the serum CHOP and GRP78 levels and the severity of the FICAT stages. A total of 42 ONFH patients at FICAT stage 3, 40 patients at FICAT stage 4, and 49 FNF patients received total hip replacement (THR). The mRNA and protein levels of CHOP and GRP78 were elevated in necrotic area compared to the non-necrotic area of ONFH patients and the FH tissues of FNF patients with statistical significance. The expression levels of CHOP and GRP78 within the local tissues were significantly elevated in patients at FICAT stage 4 as opposed to those at stage 3. Besides, ROC curve analysis indicated that serum and local CHOP and GRP78 expressions may act as indicators of disease progression. The levels of CHOP and GRP78, both in serum and at the local site, were in a positive correlation with VAS scores but an inverse relationship with HHS.

CONCLUSIONS

Serum and local GRP78 as well as CHOP expressions were positively linked with disease progression in NT-ONFH patients. Potential therapeutics targeting ER stress related protein may serve as a method for alleviating NT-ONFH.

Exosomal miR-122 derived from M2 macrophages induces osteogenic differentiation of bone marrow mesenchymal stem cells in the treatment of alcoholic osteonecrosis of the femoral head

Alcoholic osteonecrosis of the femoral head (AIONFH) is caused by long-term heavy drinking, which leads to abnormal alcohol and lipid metabolism, resulting in femoral head tissue damage, and then pathological necrosis of femoral head tissue. If not treated in time in clinical practice, it will seriously affect the quality of life of patients and even require hip replacement to treat alcoholic femoral head necrosis. This study will confirm whether M2 macrophage exosome (M2-Exo) miR-122 mediates alcohol-induced BMSCs osteogenic differentiation, ultimately leading to the inhibition of femoral head necrosis. M2 macrophages were identified by flow cytometry, and the isolated exosomes were characterized by transmission electron microscopy (TEM) and Nanoparticle Tracking Analysis (NTA). Next, miR-122 was overexpressed by transfecting miR-122 mimic, and the expression of miR-122 in M2 macrophages and their exosomes was evaluated. Subsequently, the effect of exosomal miR-122 on the osteogenic differentiation ability of BMSCs was detected, including cell proliferation, expression of osteogenic-related genes (RUNX2, BMP2, OPN, ALP), and calcium nodule formation. Finally, the therapeutic effect of M2-Exo was analyzed in a rat model of AIONFH, and bone repair and pathological damage were evaluated by Micro-CT, RT-qPCR, HE, Masson staining, and immunohistochemistry (COL I). The results showed that M2 macrophages were successfully polarized, with an average M2-Exo particle size of 156.4 nm and a concentration of 3.2E + 12 particles/mL. The expression of miR-122 in M2 macrophages is significantly higher than that in M0 macrophages, and miR-122 mimic can increase the content of miR-122 in M2-Exo. miR-122 in M2-Exo can promote osteogenic differentiation of rat bone marrow BMSCs, enhance cell viability, and increase the expression of osteogenesis-related genes. After being applied to the AIONFH rat model, the injection of M2-exo and miR-122 mimics significantly improved the repair effect of articular cartilage, alleviated pathological changes, and promoted the regeneration of bone tissue. M2-macrophage-derived exosomal miR-122 induces osteogenic differentiation of bone mesenchymal stem cells in treating AIONFH.

Location or size? A finite element analysis study of necrotic lesion impact on femoral head collapse

BACKGROUND

The location and size of necrotic lesions are important factors for collapse, The preserved angles (PAs) are divided into anterior preserved angle (APA) and lateral preserved angle (LPA), which could accurately measure the location of necrosis lesion. We used them to evaluate the effect of the location and size of necrotic lesions on collapse by finite element analysis, to offer a framework for evaluating the prognosis of osteonecrosis of the femoral head (ONFH) in clinical settings.

METHODS

3 left hip models were constructed based on CT data. Within each hip model, three necrosis lesion models were modeled, with necrotic tissue volumes of 30%, 50%, and 70% repectively. The ONFH models with LPA of 45.5°, 50.5°, 55.5°, 60.5°, 65.5°, 70.5°, and 75.5° when APA was 60.5°, and ONFH models with APAs of 45.5°, 50.5°, 55.5°, 60.5°, 65.5°, 70.5°, and 75.5° when LPA was 60.5° were Constructed. The maximum von Mises stess of the femoral head and necrotic lesion, as well as the femoral head displacement, were calculated to evaluate the biomechanical effects of these models.

RESULTS

(1) In models with the same necrotic volume, when APA was 60.5°, the indexes of the LPA < 60.5° models were significantly higher than those of the LPA ≥ 60.5° models (P < 0.05); the differences of the indexes among the LPA ≥ 60.5° models were not statistically significant (P > 0.05). (2) When LPA was 60.5°, the indexes of models with APA < 60.5 ° and APA ≥ 60.5 ° show the same trend as the former. (3) In the models with the same PAs, there was no statistically significant difference in the indexes (P > 0.05).

CONCLUSION

The location of the necrotic lesion exerts a greater impact on femoral head collapse compared with the size of the lesion. The location of the necrosis may deserve more consideration when assessing the risk of collapse in patients with early onset ONFH.

Integrated bioinformatics analysis and experimental validation of exosome-related gene signature in steroid-induced osteonecrosis of the femoral head

BACKGROUND

Steroid-induced osteonecrosis of the femoral head (SIONFH) is a universal hip articular disease and is very hard to perceive at an early stage. The understanding of the pathogenesis of SIONFH is still limited, and the identification of efficient diagnostic biomarkers is insufficient. This research aims to recognize and validate the latent exosome-related molecular signature in SIONFH diagnosis by employing bioinformatics to investigate exosome-related mechanisms in SIONFH.

METHOD

The GSE123568 and GSE74089 datasets were employed to conduct differentially expressed genes (DEGs) analysis, and the GSE123568 dataset was subjected to perform weighted genes co-expression network analysis (WGCNA). The exosome-related genes (ERGs) were retrieved from the GeneCards database. We identified differentially expressed exosome-related genes (DEERGs) between healthy controls (HC) and SIONFH patients, and a consensus clustering analysis was then implemented to group the SIONFH patients. The CIBERSORT was implemented to calculate the immune cell infiltration. Gene Set Variation Analysis (GSVA), Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) were conducted to investigate latent enriched pathways. In addition, machine-learning algorithms were applied to refine the DEERGs. Ultimately, we verified the diagnostic significance and expression of the hub genes using the SIONFH datasets and performing quantitative reverse transcription polymerase chain reaction (qRT-PCR) analysis.

RESULTS

This study identified twenty DEERGs from the peripheral serum and hip articular cartilage samples of SIONFH patients and HC. Two SIONFH subtypes related to ERGs were identified, and distinctions in pathways and immune cell infiltration patterns were compared. SIONFH's high-risk subpopulation exhibited enriched immune-related pathways and high immune cell infiltration, such as M0 macrophages, resting mast cells, and neutrophils. Three machine-learning algorithms then determined LCP1, PNP, UBE2V1, and ZFP36 as four exosome-related hub genes (ERHGs). Compared to HC samples, these ERHGs showed excellent diagnostic efficiency (overall AUC for ERHGs is in the range of 0.923 to 0.970 in GSE123568) in SIONFH samples. LCP1, PNP, UBE2V1, and ZFP36 expressions were validated in the GSE123568 and GSE74089 datasets and finally detected in peripheral serum samples with accordant expression by RT-qPCR.

CONCLUSION

Twenty potential exosome-related genes involved in SIONFH were identified through bioinformatics analysis. LCP1, PNP, UBE2V1, and ZFP36 might become candidate biomarkers and therapeutic targets because they have an intimate relationship with exosomes. These findings shed light on the exosome-related acquaintance of SIONFH and might contribute to the diagnosis and prognosis of SIONFH.

Aiding Diagnosis and Classifying of Early Stage Osteonecrosis of the Femoral Head with Convolutional Neural Network Based on Magnetic Resonance Imaging

Introduction

The Steinberg classification system is commonly used by orthopedic surgeons to stage the severity of patients with osteonecrosis of the femoral head (ONFH), and it includes mild, moderate, and severe grading of each stage based on the area of the femoral head affected. However, clinicians mostly grade approximately by visual assessment or not at all. To accurately distinguish the mild, moderate, or severe grade of early stage ONFH, we propose a convolutional neural network (CNN) based on magnetic resonance imaging (MRI) of the hip joint of patients to accurately grade and aid diagnosis of ONFH.

Materials and Methods

T1-MRI images of patients diagnosed with early stage ONFH were collected. Three orthopedic surgeons selected 261 slices containing images of the femoral head and labeled each case with the femoral head necrosis classification. Our CNN model learned, trained, and segmented the regions of femoral head necrosis in all the data.

Results

The accuracy of the proposed CNN for femoral head segmentation is 97.73%, sensitivity is 91.17%, specificity is 99.40%, and positive predictive value is 96.98%. The diagnostic accuracy of the overall framework is 90.80%.

Conclusions

Our proposed CNN model can effectively segment the region where the femoral head is in MRI and can identify the region of early stage femoral head necrosis for the purpose of aiding diagnosis.

Global incidence of osteonecrosis of the femoral head after femoral neck fracture surgery in adolescents: a meta-analysis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a significant postoperative complication following femoral neck fractures (FNFs) in adolescents, that has garnered considerable attention from researchers. Despite this interest, the incidence of ONFH in adolescents post-FNF surgery has not been extensively evaluated. To contribute to the body of research, we performed a meta-analysis utilizing articles sourced from multiple databases, with an emphasis on the rate of ONFH occurrence in young adolescents following FNF surgery.

OBJECTIVE

The purpose of this study was to investigate the incidence of ONFH after FNFs in adolescents worldwide and analyse potential risk factors affecting its occurrence to provide guidance for the treatment and rehabilitation after FNFs in adolescents and reduce the incidence of ONFH.

METHODS

A comprehensive search of medical literature databases, including MEDLINE, Web of Science, the Cochrane Library, and Embase, was conducted to identify relevant studies on ONFH and its associated risk factors after surgical treatment for FNFs in adolescents, covering the period from the establishment of the database to April 2024. Studies that did not meet the inclusion criteria were excluded. The study was conducted based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Literature extraction, management, and data entry were performed using Zotero 6.0 and Excel 2016. The meta-analysis was conducted using R Studio 4.2.2. Subgroup analysis, sensitivity analysis, and assessment of publication bias were performed to explore sources of heterogeneity and evaluate the reliability of the results. This study has been registered on Prospero. (registration number: CRD4202452794; date of registration: 03/04/2024) RESULTS: A total of 17 publications involving 862 patients with FNFs were included in this meta-analysis. The findings revealed that the incidence of ONFH after FNF surgery in adolescents was 24.02% [95% CI (0.2118, 0.2712)]. The included studies demonstrated good consistency, and no publication bias was observed.

CONCLUSION

This study revealed that the incidence of ONFH after FNFs in adolescents is high (24.02%). Early screening and effective treatment of postoperative patients are crucial.

ERAS perioperative management measures in total hip replacement in HIV-positive patients with osteonecrosis of the femoral head

OBJECTIVE

This study aims to investigate the feasibility and effectiveness of enhanced recovery after surgery (ERAS) in HIV-positive patients diagnosed with osteonecrosis of the femoral head (ONFH) undergoing total hip replacement (THR).

METHODS

We retrospectively included 80 HIV-positive patients diagnosed with ONFH who underwent THR between 2011 and 2022. Forty patients treated before August 2019 constituted the control group, receiving standard antiviral regimens and traditional perioperative management pathways. The remaining 40 patients, treated after August 2019, formed the study group, which followed the ERAS protocol. This protocol emphasized the use of more effective antiviral medications, rapid viral load reduction, immune enhancement, improved nutritional status, control of co-infections, prophylactic antibiotics, and anti-osteoporosis measures. We recorded patients' general status and imaging examinations before surgery, as well as detailed perioperative management strategies, antiviral regimens, durations, and immunological indicators for both groups. Targeted and standardized treatment measures were applied to the ERAS group, allowing for a comparison of the efficacy of perioperative management between the two patient groups.

RESULTS

Preoperative nutritional and immune indicators were lower in the control group than in the study group, while inflammatory markers were higher. Postoperatively, immune, nutritional, and inflammatory indicators were significantly better in the ERAS group compared to the control group. Following antiviral treatment, the viral load was predominantly undetectable in the ERAS group (target not detected, TND). Comprehensive measures minimized complications in the ERAS group (P = 0.028, P < 0.05). The hospitalization duration for the ERAS group was significantly shorter than that of the control group, with both groups showing marked improvement compared to preoperative conditions and no incidents of loosening or dislocation.

CONCLUSION

Strengthening antiviral treatment, anti-infective strategies, incision care, and nutritional support effectively prevents and reduces complications such as delayed wound healing in HIV-positive patients. The implementation of ERAS measures requires careful attention to the patient's immune status, close monitoring of clinical changes, and timely adjustments to treatment and care plans.

LEVEL OF EVIDENCE

Treatment studies.

A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a progressive and debilitating condition characterized by the death of bone tissue due to inadequate blood supply. Despite advances in diagnostic imaging and treatment strategies, predicting the risk of femoral head collapse remains a significant clinical challenge. This study seeks to address this gap by developing a robust prognostic model that integrates clinical, imaging, and laboratory data to improve early diagnosis and guide therapeutic decision-making.

METHODS

We conducted a qualitative systematic review and employed the Delphi method to select key prognostic factors from clinical data, imaging findings, and laboratory indicators. The study included ONFH patients treated from January 2014 to December 2021. We used univariate and multivariate Cox regression analyses to develop a nomogram for predicting the risk of femoral head collapse. The model's performance was evaluated using the concordance index (C-index), calibration plots, and decision curve analysis (DCA).

RESULTS

The study included 297 patients (454 hips) with ONFH. Key prognostic factors identified included pain presence (p < 0.001, RR = 0.185, 95% CI: 0.11-0.31), JIC classification (C1: p < 0.001, RR = 0.096, 95% CI: 0.054-0.171; C2: p < 0.001, RR = 0.323, 95% CI: 0.215-0.487), necrotic area (3 < MNAI < 6: p < 0.001, RR = 0.107, 95% CI: 0.061-0.190; MNAI ≥ 6: p < 0.001, RR = 0.466, 95% CI: 0.314-0.692), weight-bearing reduction (p < 0.001, RR = 0.466, 95% CI: 0.323-0.672), preservation of the anterolateral pillar (p < 0.001, RR = 0.223, 95% CI: 0.223-0.473), and subchondral bone fracture on CT (p < 0.001, RR = 0.32, 95% CI: 0.217-0.472). The nomogram demonstrated a high C-index of 0.88, indicating excellent predictive accuracy. Calibration plots showed good agreement between predicted and observed outcomes, and DCA confirmed the model's clinical utility.

CONCLUSIONS

The prognostic model developed in this study provides a reliable tool for predicting femoral head collapse in ONFH patients. It allows for early identification of high-risk patients, guiding personalized treatment strategies to improve patient outcomes and reduce the need for invasive surgical procedures.

Predicting steroid-induced osteonecrosis of the femoral head: role of lipid metabolism biomarkers and radiomics in young and middle-aged adults

BACKGROUND

Femoral head necrosis is a common orthopedic disease that results in significant physical disability in patients. Early prediction and diagnosis of steroid-induced osteonecrosis of the femoral head (SONFH) are crucial for the prevention and treatment of this condition.

METHODS

In this study, initial CT images and clinical data of patients with SONFH, admitted from January 2019 to December 2022, were collected. Patients were grouped as follows: (1) those diagnosed with SONFH at the initial diagnosis (control group), and (2) those with high-risk factors but no symptoms at first diagnosis, who developed SONFH two years later (experimental group). CT imaging histological features, clinical characteristics, and transcriptome screening for differentially expressed genes, pathway enrichment, and immune infiltration analyses were performed.

RESULTS

Significant differences were found in triglyceride (TG) levels between the training and validation groups. Age, sex, alkaline phosphatase (ALP), and hemoglobin levels differed between the training and internal validation groups, while HDL and red blood cell counts varied between the training and external validation groups. Univariate analysis showed that age, TG, HDL, and Radiomics scores influenced SONFH, while multivariate analysis revealed TG, HDL, and Radiomics scores were closely related to SONFH. Transcriptomic analysis showed associations with sphingolipid and adipocyte signaling pathways, along with immune cell involvement, linking SONFH to lipid metabolism and atherosclerosis.

CONCLUSIONS

These findings indicate a significant association between steroid-induced osteonecrosis of the femoral head and age, with TG and HDL serving as indicators of lipid metabolism closely correlated with the occurrence of SONFH. Radiomics scores were also found to correlate with SONFH occurrence, supported by transcriptomic and CT imaging findings. However, this study has limitations, including its retrospective design and a relatively limited sample size, which may impact the generalizability of the results. Further prospective studies with larger, more diverse populations are needed to validate and enhance the predictive model.

Preliminary study of the role of histone deacetylase (HDAC) in steroid-induced avascular necrosis of the femoral head induced by BMSC adipogenic differentiation

Our previous research revealed a close association between the acetylation of peroxisome proliferator-activated receptor γ (PPARγ) histone H3K27 and the adipogenic differentiation of bone marrow mesenchymal stem cells (BMSCs). We preliminarily explored the epigenetic mechanism of steroid-induced avascular necrosis of the femoral head (SANFH) development, but the specific histone deacetylase (HDAC) involved in this regulatory process remains unknown. In this study, we combined cell, animal, and clinical specimen experiments to screen for specific HDAC genes that could regulate BMSC adipogenic differentiation and to explore their roles. The results showed that dexamethasone (DEX) significantly exacerbated the imbalance between the adipogenic and osteogenic differentiation of BMSCs, and there were differences in HDAC expression in the adipogenic differentiation cell models, with histone deacetylase 10 (HDAC10) showing the most significant decrease in expression. Subsequent use of a chromatin immunoprecipitation assay kit and quantitative polymerase chain reaction (ChIP‒qPCR) revealed a decrease in HDAC10 expression at predicted potential sites within the PPARγ promoter, indicating a significant decrease in HDAC10 enrichment in the PPARγ promoter region of BMSCs, thereby promoting sustained PPARγ expression. Additionally, immunohistochemistry of samples collected from mice and humans with SANFH and normal femoral heads revealed an imbalance between adipogenic and osteogenic differentiation in the necrotic area of femoral heads, with a significant decrease in the relative expression of HDAC10 in the necrotic area of femoral heads with SANFH. In summary, we speculate that HDAC10 affects the progression of SANFH by regulating BMSC adipogenic differentiation, a process possibly related to PPARγ histone acetylation. These findings provide a promising direction for the treatment of SANFH.

Recent trends of stem cell therapies in the management of orthopedic surgical challenges

Emerged health-related problems especially with increasing population and with the wider occurrence of these issues have always put the utmost concern and led medicine to outgrow its usual mode of treatment, to achieve better outcomes. Orthopedic interventions are one of the most concerning hitches, requiring advancement in several issues, that show complications with conventional approaches. Advanced studies have been undertaken to address the issue, among which stem cell therapy emerged as a better area of growth. The capacity of the stem cells to renovate themselves and adapt into different cell types made it possible to implement its use as a regenerative slant. Harvesting the stem cells, particularly mesenchymal stem cells (MSCs) is easier and can be further grown in vitro . In this review, we have discussed orthopedic-related issues including bone defects and fractures, nonunions, ligament and tendon injuries, degenerative changes, and associated conditions, which require further approaches to execute better outcomes, and the advanced strategies that can be tagged along with various ways of application of MSCs. It aims to objectify the idea of stem cells, with a major focus on the application of MSCs from different sources in various orthopedic interventions. It also discusses the limitations, and future scopes for further approaches in the field of regenerative medicine. The involvement of MSCs may transition the procedures in orthopedic interventions from predominantly surgical substitution and reconstruction to bio-regeneration and prevention. Nevertheless, additional improvements and evaluations are required to explore the effectiveness and safety of mesenchymal stem cell treatment in orthopedic regenerative medicine.

Three-dimensional mapping of necrotic lesions for early-stage osteonecrosis of the femoral head

BACKGROUND

There is a scarcity of evidence regarding the potential relationship between the size and location of necrotic lesions, which must be understood to provide optimal joint-preserving treatment. The purpose of this study was to characterize the distribution patterns of necrotic lesions of varying sizes in early-stage osteonecrosis of femoral head (ONFH) with the use of three-dimensional mapping.

METHODS

We retrospectively evaluated clinical CT images of the hips that were performed in the Third Hospital of Hebei Medical University from January 2018 to December 2022 and collected all CT images diagnosed with stage I and II ONFH. Three-dimensional structures that included both necrotic lesions and normal areas of the femoral heads were reconstructed and divided into eight regions to record their size and location. CT images for all lesions were superimposed onto a standard template, and three-dimensional mapping was created to determine the presence of concentrated areas of lesions.

RESULTS

In a cohort of 143 patients with stage I and II ONFH, a total of 150 hips were reviewed. For lesions with less than 15% of the femoral head volume, necrotic lesions predominantly involve regions I, III, and V, with region I showing concentration. For lesions with volumes ranging from 15 to 30%, necrotic lesions exhibited a wider distribution across regions I, II, III, IV, V, and VII, with significant concentrations in regions I, III, and V. For lesions exceeding 30% of the femoral head volume, the necrotic lesions were extensively distributed across nearly the entire femoral head, with a notable expansion of the concentrated necrotic areas.

CONCLUSIONS

The distribution of necrotic lesions varies with lesion size, with smaller lesions primarily concentrated in the anterior and medial regions of the femoral head, particularly in the anterosuperior region, while larger lesions expand to the lateral and inferior regions. These findings enhance existing classification systems and provide crucial insights for guiding hip-preserving surgical planning and approaches.

Loss of walking independence one year after primary total hip arthroplasty for osteonecrosis of the femoral head: incidence and risk prediction model

BACKGROUND

Assessment of postoperative ambulation in osteonecrosis of the femoral head (ONFH) patients treated with total hip arthroplasty (THA) is limited. This study aimed to define the incidence and risk factors for losing walking independence (LWI) at one-year postoperatively in patients with ONFH undergoing primary THA, and to establish and validate a predictive nomogram.

METHODS

This was a retrospective analysis of prospective collected data from patients admitted to a tertiary referral hospital with ONFH who underwent primary unilateral THA from October 2014 to March 2018. The Functional Independence Measure-Locomotion scale was used to quantify walking independence and was documented at a one-year continuous postoperative follow-up, which classified patients with a final score below 6 as LWI. Multivariate logistic regression identified independent risk factors for LWI, and a predictive nomogram was constructed based on the analysis results. The stability of the model was assessed using patients from April 2018 to April 2019 as an external validation set.

RESULTS

1152 patients were enrolled in the study, of which 810 were used in the training cohort and the other 342 for the validation cohort. The incidence of LWI was 5.93%. Multivariate analysis revealed that age 62 years or older (odd ratio (OR) = 2.37, 95% confidence interval (CI) 1.07-5.24), Charlson's comorbidity index 3 or higher (OR = 3.64, 95% CI 1.09-12.14), Association Research Circulation Osseous stage IV (OR = 2.16, 95% CI 1.03-4.54), reduced femoral offset (OR = 2.41, 95% CI 1.16-5.03), and a higher controlling nutritional status score (OR = 1.14, 95% CI 1.01-1.30) were independent risk factors of LWI. The nomogram had a concordance index of 0.773 and a Brier score of 0.049 in the training set, with corrected values of 0.747 and 0.051 after internal validation. The receiver-operating characteristic curve, calibration curve, Hosmer-Lemeshow test, and decision curve analysis all performed well in both the training and validation cohorts.

CONCLUSIONS

This study reported a 5.93% incidence of LWI and established a risk prediction model in patients undergoing THA for ONFH, supporting targeted screening and intervention to assist surgeons in assessing ambulation capacity and managing rehabilitation.

Spherical varus rotational osteotomy of the femur using a navigation system as extra-articular surgery for extensive osteonecrosis of femoral head: a case control study

BACKGROUND

Curved varus osteotomy (CVO) is an effective femoral head-preserving surgical procedure for osteonecrosis of the femoral head (ONFH) classified as type B or C1 according to the Japanese Investigation Committee (JIC) classification; it reportedly provides better postoperative outcomes than transtrochanteric rotational osteotomy (TRO). We have developed a new procedure called spherical varus rotational osteotomy (SVRO) in which osteotomy of the femur into a spherical shape is followed by varus and anterior rotation using navigation to increase indications and improve postoperative outcomes.

METHODS

Nine joints of eight patients who underwent SVRO and could be followed up for > 1 year were included in the study. Disease types determined preoperatively according to the JIC classification were type C1 for four joints and type C2 for five joints. Preoperative disease JIC classification stages were 3a for eight joints and 1 for one joint. SVRO was performed using OrthoMap® 3D Navigation software, and the following variables were measured: surgery time, intraoperative blood loss, difference between preoperative and postoperative angles of anteversion, postoperative lower limb length discrepancy, and postoperative intact area occupancy. The Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) was used for clinical evaluation. Visual Analog Scale and JHEQ scores were evaluated preoperatively and at the final follow-up.

RESULTS

The measurement results were as follows: surgery time, 130 min; blood loss, 200 ml; angle of varus, 20°; angle of anterior rotation, 30°; preoperative angle of anteversion, 15°; postoperative angle of anteversion, 22°; lower limb shortening, 11 mm; preoperative intact area occupancy, 0%; and postoperative intact area occupancy, 74.2%. There were no cases of progression in the postoperative stages or re-collapse.

CONCLUSION

SVRO allows for the repositioning of the exterior and posterior intact areas, providing a broader intact region postoperatively. This technique is particularly beneficial for young patients with ONFH and extensive necrosis and is a less invasive alternative to TRO. This procedure has been shown to be effective in achieving favorable outcomes in patients with extensive necrosis who would have otherwise required rotational osteotomy, depending on the necrosis location. Further longitudinal studies are necessary to validate these findings and establish long-term benefits.

Surgical hip dislocation technique through the femoral head fovea fenestration and impaction bone grafting for the treatment of non-traumatic osteonecrosis of the femoral head: a retrospective study

BACKGROUND

Osteonecrosis of the femoral head (ONFH) often leads to the collapse of the femoral head, ultimately resulting in patients undergoing premature total hip arthroplasty (THA). The surgical hip dislocation (SHD) technique is a type of hip-preserving surgery aimed at delaying or avoiding THA. This study aims to evaluate the clinical efficacy of SHD techniques through femoral head fovea fenestration and impaction bone grafting for the treatment of non-traumatic ONFH.

METHODS

A retrospective analysis was conducted on the clinical data of 39 patients (39 hips) with non-traumatic ONFH who underwent SHD for treatment from 2016 to 2017. The Harris hip score (HHS) and the minimum clinically important difference (MCID) are used to evaluate clinical outcomes, while radiographic evaluations are conducted using X-rays. Kaplan-Meier survival analysis defined clinical failure as further THA, and conducted univariate survival analysis and Cox regression analysis. Any complications were recorded.

RESULTS

All patients were followed up for 24-72 months, with an average of (60 ± 13.0) months. At the last follow-up, based on the HHS, 25 patients (64.1%) reported excellent and good clinical outcomes. 29 patients (74.3%) achieved MCID. Imaging evaluation of the postoperative femoral head status showed that 6 cases improved, 20 cases remained stable, and 13 cases showed progressed. Out of 39 hips, 12 hips had postoperative clinical failure, resulting in a clinical success rate of 69.2%. Association Research Circulation Osseous (ARCO) stage, China-Japan Friendship Hospital (CJFH) classification, and postoperative crutch-bearing time are risk factors for clinical failure. Postoperative crutch-bearing time of less than 3 months is an independent risk factor for clinical failure. After surgery, there was one case of sciatic nerve injury and one case of heterotopic ossification. There were no infections or non-union of the greater trochanter osteotomy.

CONCLUSION

The SHD technique through the femoral head fovea fenestration and impaction bone grafting provides a safe and effective method for treating non-traumatic ONFH, with good mid-term clinical outcomes. ARCO staging, CJFH classification, and postoperative crutch-bearing time are risk factors that affect clinical outcomes after surgery and lead to further THA. Insufficient postoperative crutch-bearing time is an independent risk factor for clinical failure.

Comparison of clinical efficacy of robot-assisted and freehand core decompression in the treatment of osteonecrosis of the femoral head: a systematic review and meta-analysis

OBJECTIVE

At present, the core decompression (CD) has become the main surgical procedure for the treatment of osteonecrosis of the femoral head (ONFH); however, the CD surgery requires high operator experience and repeated fluoroscopy increases the radiation damage to patients, and medical staff. This article compares the clinical efficacy of robot-assisted and freehand CD for ONFH by meta-analysis.

METHODS

Computer searches of PubMed, Web of Science, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, China Science and Technology Journal Database, WanFang, and Chinese BioMedical Literature Database were conducted from the time of database inception to November 15, 2023. The literature on the clinical efficacy of robot-assisted and freehand CD in the treatment of ONFH was collected. Two researchers independently screened the literature according to the inclusion and exclusion criteria, extracted data, and strictly evaluated the quality of the included literature. Outcome measures encompassed operative duration, intraoperative blood loss volume, frequency of intraoperative fluoroscopies, visual analog scale (VAS) score, Harris hip score (HHS), complications, and radiographic progression. Data synthesis was carried out using Review Manager 5.4.1 software. The quality of evidence was evaluated according to Grades of Recommendation Assessment Development and Evaluation (GRADE) standards.

RESULTS

Seven retrospective cohort studies involving 355 patients were included in the study. The results of meta-analysis showed that in the robot-assisted group, the operative duration (MD = -17.60, 95% CI: -23.41 to -11.78, P < 0.001), intraoperative blood loss volume (MD = -19.98, 95% CI: -28.84 to -11.11, P < 0.001), frequency of intraoperative fluoroscopies (MD = -6.60, 95% CI: -9.01 to -4.20, P < 0.001), and ΔVAS score (MD = -0.45, 95% CI: -0.67 to -0.22, P < 0.001) were significantly better than those in the freehand group. The GRADE evidence evaluation showed ΔVAS score as low quality and other indicators as very low quality. There was no significant difference in the terms of ΔHHS (MD = 0.51, 95% CI: -1.34 to 2.35, P = 0.59), complications (RR = 0.30, 95% CI: 0.03 to 2.74, P = 0.29), and radiographic progression (RR = 0.50, 95% CI: 0.25 to 1.02, P = 0.06) between the two groups.

CONCLUSION

There is limited evidence showing the benefit of robot-assisted therapy for treatment of ONFH patients, and much of it is of low quality. Therefore, caution should be exercised in interpreting these results. It is recommended that more high-quality studies be conducted to validate these findings in future studies.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/ #recordDetails, CRD42023420593.

Astaxanthin-mediated Nrf2 activation ameliorates glucocorticoid-induced oxidative stress and mitochondrial dysfunction and impaired bone formation of glucocorticoid-induced osteonecrosis of the femoral head in rats

BACKGROUND

Osteonecrosis of the femoral head caused by glucocorticoids (GIONFH) is a significant issue resulting from prolonged or excessive clinical glucocorticoid use. Astaxanthin, an orange-red carotenoid present in marine organisms, has been the focus of this study to explore its impact and mechanism on osteoblast apoptosis induced by dexamethasone (Dex) and GIONFH.

METHODS

In this experiment, bioinformatic prediction, molecular docking and dynamics simulation, cytotoxicity assay, osteogenic differentiation, qRT-PCR analysis, terminal uridine nickend labeling (TUNEL) assay, determination of intracellular ROS, mitochondrial function assay, immunofluorescence, GIONFH rat model construction, micro-computed tomography (micro-CT) scans were performed.

RESULTS

Our research demonstrated that a low dose of astaxanthin was non-toxic to healthy osteoblasts and restored the osteogenic function of Dex-treated osteoblasts by reducing oxidative stress, mitochondrial dysfunction, and apoptosis. Furthermore, astaxanthin rescued the dysfunction in poor bone quality, bone metabolism and angiogenesis of GIONFH rats. The mechanism behind this involves astaxanthin counteracting Dex-induced osteogenic damage by activating the Nrf2 pathway.

CONCLUSION

Astaxanthin shields osteoblasts from glucocorticoid-induced oxidative stress and mitochondrial dysfunction via Nrf2 pathway activation, making it a potential therapeutic agent for GIONFH treatment.

Epidemiological investigation and diagnostic analysis of osteonecrosis of the femoral head in three northeastern provinces of China

BACKGROUND

In this retrospective case investigation, we analysed the data of patients with osteonecrosis of the femoral head (ONFH) to reveal demographic and clinical diagnostic features of ONFH in three northeastern provinces of China and provide a reference for its prevention, diagnosis, and treatment.

METHODS

We collected data from patients in Beijing Orthopaedic Hospital of Liaoning, focusing on the aetiology and diagnosis of ONFH. Medical records and self-designed questionnaires were used to collect information for statistical analysis, including age, aetiology, reason for glucocorticoid use, hospital level at first visit, and diagnosis.

RESULTS

In total, 906 patients with complete medical records were included in the analysis. The mean patient age was 47.65 ± 12.12 years. The peak age distribution was in the 40s for men and the 50s for women. Among the total cohort, 72 patients (7.95%; 40 men and 32 women) had traumatic ONFH, 198 (21.85%; 131 men and 67 women) had steroid-induced ONFH, 230 (25.39%; 121 men and 109 women) had idiopathic ONFH, and 406 (44.81%; 397 men and 9 women) had alcohol-induced ONFH. Six hundred and twenty patients were diagnosed with ONFH at the first visit, while 286 patients were misdiagnosed, with a diagnosis rate of 68.43%. The diagnosis rate at the first visit in tertiary hospitals was 76.14%. The diagnosis rate at the first visit in second-class hospitals was 52.07%.ONFH was most likely to be misdiagnosed as lumbar disc herniation.

CONCLUSIONS

Most patients with ONFH in three northeastern provinces of China were middle-aged, male, and had alcohol-induced ONFH. The misdiagnosis rate of ONFH at the first visit was very high, especially for misdiagnosis of lumbar disc herniation, indicating that the diagnosis of ONFH requires further improvement.

Research progress in the pathogenesis of hormone-induced femoral head necrosis based on microvessels: a systematic review

Hormonal necrosis of the femoral head is caused by long-term use of glucocorticoids and other causes of abnormal bone metabolism, lipid metabolism imbalance and blood microcirculation disorders in the femoral head, resulting in bone trabecular fracture, bone tissue necrosis collapse, and hip dysfunction. It is the most common type of non-traumatic necrosis of the femoral head, and its pathogenesis is complex, while impaired blood circulation is considered to be the key to its occurrence. There are a large number of microvessels in the femoral head, among which H-type vessels play a decisive role in the "angiogenesis and osteogenesis coupling", and thus have an important impact on the occurrence and development of femoral head necrosis. Glucocorticoids can cause blood flow injury of the femoral head mainly through coagulation dysfunction, endothelial dysfunction and impaired angiogenesis. Glucocorticoids may inhibit the formation of H-type vessels by reducing the expression of HIF-1α, PDGF-BB, VGEF and other factors, thus causing damage to the "angiogenesis-osteogenesis coupling" and reducing the ability of necrosis reconstruction and repair of the femoral head. Leads to the occurrence of hormonal femoral head necrosis. Therefore, this paper reviewed the progress in the study of the mechanism of hormone-induced femoral head necrosis based on microvascular blood flow at home and abroad, hoping to provide new ideas for the study of the mechanism of femoral head necrosis and provide references for clinical treatment of femoral head necrosis.

Exosomes derived from M2 macrophages prevent steroid-induced osteonecrosis of the femoral head by modulating inflammation, promoting bone formation and inhibiting bone resorption

Inflammatory reactions are involved in the development of steroid-induced osteonecrosis of the femoral head(ONFH). Studies have explored the therapeutic efficacy of inhibiting inflammatory reactions in steroid-induced ONFH and revealed that inhibiting inflammation may be a new strategy for preventing the development of steroid-induced ONFH. Exosomes derived from M2 macrophages(M2-Exos) display anti-inflammatory properties. This study aimed to examine the preventive effect of M2-Exos on early-stage steroid-induced ONFH and explore the underlying mechanisms involved. In vitro, we explored the effect of M2-Exos on the proliferation and osteogenic differentiation of bone marrow-derived mesenchymal stem cells(BMMSCs). In vivo, we investigated the role of M2-Exos on inflammation, osteoclastogenesis, osteogenesis and angiogenesis in an early-stage rat model of steroid-induced ONFH. We found that M2-Exos promoted the proliferation and osteogenic differentiation of BMMSCs. Additionally, M2-Exos effectively attenuated the osteonecrotic changes, inhibited the expression of proinflammatory mediators, promoted osteogenesis and angiogenesis, reduced osteoclastogenesis, and regulated the polarization of M1/M2 macrophages in steroid-induced ONFH. Taken together, our data suggest that M2-Exos are effective at preventing steroid-induced ONFH. These findings may be helpful for providing a potential strategy to prevent the development of steroid-induced ONFH.

Orthopedic Challenges in Avascular Necrosis Management: A Case Report of Surgical Complications and Multidisciplinary Care

A 52-year-old woman, with a multifaceted medical background encompassing spinal cord injury, pneumonia, and recurrent hospitalizations, presents with enduring left hip and leg discomfort ultimately diagnosed as avascular necrosis (AVN). She previously underwent intraosseous direct anterior arthroplasty (DAA) of the left hip during the removal of orthopedic artifacts. Despite enduring hypertension, severe trochanter dislocation, and prosthesis fracture, she recovered and required additional surgery to address the dislocation and fracture. This case underscores the challenges in diagnosing and treating AVN, emphasizing the importance of meticulous postoperative care and a multidisciplinary approach. Challenges highlighted by AVN include delayed diagnosis, intricate surgical procedures, and the potential need for further interventions due to hardware complications and infection as seen in this patient.

Femoral rotational osteotomy for femoroacetabular impingement: A systematic review

Purpose

To synthesize existing literature regarding the indications and outcomes of femoral rotational osteotomies (FDO) for femoroacetabular impingement (FAI) due to.

Methods

Medline, Cochrane, and Embase were searched using keywords "femoroacetabular impingement", "rotational osteotomy" and others to identify FAI patients undergoing FDO. Double-screened studies were reviewed by blinded authors according to inclusion criteria. Data from full texts was extracted including study type, number of patients, sex, mean age, surgical indication, type of dysplasia, associated pathology, surgical technique, follow-up, and pre-op/post-op evaluations of the following: impingement test, femoral version (FV), 'other angles measured', outcome scores, range of motion (ROM).

Results

7 studies including 91 patients (97 FDO surgeries), 73 females (80 %) with mean age of 28.3 years, and follow-up mean of 2.44 ± 2.83 years. Pain or impingement was the most common clinical indication, while others included aberrant FV and ROM measurements for both anteverted and retroverted femurs. There were reports of FDO being performed with concomitant procedures addressing other pathology. Various outcome scores and ROM measurements showed postoperative improvement after FDO. Complication data was sparse, preventing aggregation. The rate of unplanned reoperation was 40 % (where reported), with 'hardware removal' being the most common.

Conclusions

FDO is effective in treating FAI due to increased FV, improving clinical symptoms, and potentially delaying articular degeneration. Hardware removal surgery remains an inherent risk in undergoing FDO. Further work is needed to discover indications warranting FDO as a primary treatment versus hip arthroscopy.

Level of evidence

This review contains 4 studies with Level IV evidence and 3 studies with Level III evidence.

m6A methylation modification and immune infiltration analysis in osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a elaborate hip disease characterized by collapse of femoral head and osteoarthritis. RNA N6-methyladenosine (m6A) plays a crucial role in a lot of biological processes within eukaryotic cells. However, the role of m6A in the regulation of ONFH remains unclear. In this study, we identified the m6A regulators in ONFH and performed subtype classification. We identified 7 significantly differentially expressed m6A regulators through the analysis of differences between ONFH and normal samples in the Gene Expression Omnibus (GEO) database. A random forest algorithm was employed to monitor these regulators to assess the risk of developing ONFH. We constructed a nomogram based on these 7 regulators. The decision curve analysis suggested that patients can benefit from the nomogram model. We classified the ONFH samples into two m6A models according to these 7 regulators through consensus clustering algorithm. After that, we evaluated those two m6A patterns using principal component analysis. We assessed the scores of those two m6A patterns and their relationship with immune infiltration. We observed a higher m6A score of type A than that of type B. Finally, we performed a cross-validation of crucial m6A regulatory factors in ONFH using external datasets and femoral head bone samples. In conclusion, we believed that the m6A pattern could provide a novel diagnostic strategy and offer new insights for molecularly targeted therapy of ONFH.

Comparison of outcomes after total hip arthroplasty between patients with osteonecrosis of the femoral head in Association Research Circulation Osseous stage III and stage IV: a five-year follow-up study

BACKGROUND

No large cohort study has evaluated the surgical outcomes of THA between different stages of ONFH patients. This study aimed to compare the surgical outcomes of ONFH patients who underwent THA in ARCO stage III versus IV, in terms of operative parameters, one-year hip function assessments and postoperative at least five-year complications, to inform optimized management of ONFH.

METHOD

From our prospectively collected database, 876 patients undergoing THA between October 2014 and April 2017 were analyzed and divided into ARCO stage III group (n = 383) and ARCO stage IV group(n = 493). Details of demographics, medical record information, adverse events and clinical scores of both groups were collected and compared. Proper univariate analysis was used for the analysis.

RESULT

There were no statistically significant differences in baseline characteristics between the two groups. Compared to ARCO stage IV patients, ARCO stage III patients showed a shorter operative time (p < 0.01), less bleeding (p < 0.01), fewer one-year readmissions (p = 0.026) and complications (p = 0.040), and significantly higher HHS (p < 0.01) one year after THA. In addition, ARCO stage IV patients seem more likely to suffer prosthesis dislocation (p = 0.031).

CONCLUSION

Although ARCO stage IV patients in the study cohorts appeared to suffer more one-year complications, no significant difference was observed at long-term follow-up. Enhanced clinical guidance on preventing early prosthesis dislocation may help improve the prognosis of final-stage ONFH patients.

Correlation of serum and local CXCL13 levels with disease severity in patients with non-traumatic osteonecrosis of femoral head

OBJECTIVE

The primary aim of the present study was to explore the potential correlation of serum / local CXCL13 expressions and disease severity in non-traumatic osteonecrosis of the femoral head (NT-ONFH).

METHODS

In total, NT-ONFH patients (n = 130) together with healthy controls (HCs, n = 130) were included in this investigation. Radiographic progression was evaluated based on the imaging criteria outlined in the ARCO classification system. To assess the diagnostic value of serum CXCL13 in relation to radiographic progression, Receiver operating characteristic (ROC) curve analysis was conducted. Serum CXCL13 levels were quantified utilizing ELISA in all participants. Furthermore, local protein/mRNA expressions of CXCL13 were examined employing immunohistochemistry, western blot, as well as RT-PCR techniques. Clinical severity was appraised using the visual analogue scale (VAS), Harris Hip Score (HHS), and Western Ontario as well as McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

The findings revealed a significant reduction in serum CXCL13 levels among NT-ONFH patients in contrast with HCs. Moreover, both mRNA and protein expressions of CXCL13 were markedly decreased in the necrotic area (NA) than the non-necrotic area (NNA) as well as the healthy femoral head tissues. Additionally, serum CXCL13 levels were substantially lower among patients classified as ARCO stage 4 than those at ARCO stage 3. The concentrations of CXCL13 in stage 3 patients were notably diminished relative to those at ARCO stage 2. Notably, serum CXCL13 levels demonstrated a negative association with ARCO grade. Furthermore, these levels were also inversely linked to VAS scores as well as WOMAC scores while displaying a positive association with HHS scores. The findings of ROC curve suggested that reduced serum CXCL13 levels could be an underlying indicator for ARCO stage.

CONCLUSIONS

The reduced levels of either serum CXCL13 or local CXCL13 were intricately linked to disease severity for patients with NT-ONFH.

Method for reconstructing femoral head blood supply by anastomosing the intraosseous artery

Background

The reconstruction of femoral head blood supply is crucial in the management of avascular necrosis and related conditions. This study presents a method for reconstructing the femoral head blood supply by anastomosing the intraosseous artery.

Methods

The femoral heads of six male Landrace swine were surgically exposed, and subcranial fractures of the femoral neck were intentionally created. Under microscopic guidance, the trophoblastic foramen of the posterior supporting artery was identified. Subsequently, a triangular bone window was carefully crafted to expose the intraosseous artery. Following the fixation of the femoral head, an anastomosis was performed between the intraosseous artery and the posterior inferior supporting artery located at the distal end of the fracture. The assessment of femoral head blood supply was conducted using Kirschner's pinhole and angiography techniques.

Results

The anastomotic intraosseous artery exhibited a vibrant red color, indicating adequate blood perfusion, and demonstrated pulsatile flow. Observation through pinholes in the surface of the femoral head revealed continuous blood flow. Angiography further confirmed the successful circulation, as the contrast agent entered the inferior retinacular artery branch originating from the deep femoral artery. The contrast agent then proceeded to enter the femoral head through the retinacular artery, reaching the anastomosis site of the intraosseous artery. Notably, the angiography also revealed the presence of visible internal branches, highlighting the establishment of a functional vascular network.

Discussion

The method of reconstructing the blood supply to the femoral head through anastomosis of the intraosseous artery enables utilization of the existing blood supply system within the femoral head. This study is just a preliminary study of this innovative technique that has the potential to prevent and/or treat femoral head necrosis following a femoral neck fracture. By restoring adequate blood flow to the affected area, this approach holds promise in preserving the viability and functionality of the femoral head, ultimately improving patient outcomes.

Analysis of the natural collapse course of non-traumatic osteonecrosis of the femoral head based on the matrix model

BACKGROUND

There are many predictions about the progression of natural collapse course of osteonecrosis of the femoral head. Here, we aimed to combine the three classical prediction methods to explore the progression of the natural collapse course.

METHODS

This retrospective study included 127 patients admitted to our hospital from October 2016 to October 2017, in whom the femoral head had not collapsed. Logistic regression analysis was performed to determine the collapse risk factors, and Kaplan-Meier survival curves were used for femoral head survival analysis. The collapse rate of the femoral head was recorded within 5 years based on the matrix model. The specificity of the matrix model was analyzed using the receiver operating characteristic curve.

RESULTS

A total of 127 patients with a total of 202 hips were included in this study, and 98 hips collapsed during the follow-up period. Multivariate logistics regression analysis showed that the predictive ability of the matrix model was stronger than Association Research Circulation Osseous staging, Japanese Investigation Committee classification, and area (P < 0.05). Kaplan-Meier survival curve showed that the median survival time of femoral head in patients was 3 years. The result of the receiver operating characteristic curve analysis showed that the area under the curve (AUC) of the matrix model had better predictive value (AUC = 0.771, log-rank test: P < 0.001).

CONCLUSION

We creatively combined the three classical prediction methods for evaluating the progression of the natural collapse course based on the matrix model and found that the higher the score of the matrix model, the higher the femoral head collapse rate. Specifically, the matrix model has a potential value in predicting femoral head collapse and guiding treatment selection.

Screening for Asymptomatic Osteonecrosis of the Hip in Systemic Lupus Erythematous: A Systematic Review and Meta-Analysis of MRI-Based Prevalence

Objective. This paper aims to estimate asymptomatic hip osteonecrosis prevalence in SLE patients using MRI examination and to determine the prevalence among higher risk subpopulations. Materials and Methods. PubMed, Embase, Cochrane, and SCOPUS were searched from inception to May 9th, 2023. Studies on patients who were clinically diagnosed with systemic lupus erythematosus without reported symptoms attributable to hip osteonecrosis were included. Two independent reviewers extracted data and assessed the risk of bias. Data collected from each study include the study year, the number of hips screened, the number of hips with osteonecrosis, demographics, laboratory data, medications, follow-up time, radiological protocols, and MRI-based osteonecrosis detection and grading criteria. Results. Eleven eligible studies including 503 participants (15-35 years old; 74-100% female) with SLE were identified. Significant risk of bias was determined in one study. The overall prevalence of osteonecrosis of the hip was found to be 14% (184/1006 hip joints, 95% confidence interval: 7-22%, number needed to scan: 7.1). SLE patients who received corticosteroid treatment had a higher prevalence of asymptomatic hip osteonecrosis (18%) compared to non-corticosteroid users (0%, p-value < 0.01). Additionally, meta-regression results revealed that daily corticosteroid dose was associated with increased prevalence of asymptomatic osteonecrosis (0.5%/milligram, p-value < 0.01). Conclusions. The high prevalence of asymptomatic hip osteonecrosis in SLE patients raises concerns about the timeliness of interventions. The limitations of this study include a relatively low number of identified studies; and one study lacked full-text availability.

Exploring molecular mechanisms of intra-articular changes in osteonecrosis of femoral head using DIA proteomics and bioinformatics

PURPOSE

This study is aimed to delve into the crucial proteins associated with hormonal osteonecrosis of the femoral head (ONFH) and its intra-articular lesions through data-independent acquisition (DIA) proteomics and bioinformatics analysis.

METHODS

We randomly selected samples from eligible ONFH patients and collected samples from the necrotic area of the femoral head and load-bearing cartilage. The control group comprised specimens from the same location in patients with femoral neck fractures. With DIA proteomics, we quantitatively and qualitatively tested both groups and analyzed the differentially expressed proteins (DEPs) between groups. Additionally, we enriched the analysis of DEP functions using gene ontology terms and Kyoto Encyclopedia of Genes and Genomes pathways and verified the key proteins in ONFH through Western blot.

RESULTS

Proteomics experiment uncovered 937 common DEPs (422 upregulated and 515 downregulated) between the two groups. These DEPs mainly participate in biological processes such as hidden attributes, catalytic activity, molecular function regulators, and structural molecule activity, and in pathways such as starch and sucrose metabolism, ECM-receptor interaction, PI3K-Akt signaling, complement and coagulation cascades, IL-17 signaling, phagosome, transcriptional misregulation in cancers, and focal adhesion. Through protein-protein interaction network target gene analysis and Western blot validation, we identified C3, MMP9, APOE, MPO, LCN2, ELANE, HPX, LTF, and THBS1 as key proteins in ONFH.

CONCLUSIONS

With DIA proteomics and bioinformatics analysis, this study reveals the molecular mechanisms of intra-articular lesions in ONFH. A correlation in the necrotic area and load-bearing cartilage of ONFH at ARCO stages IIIB-IV as well as potential key regulatory proteins was identified. These findings will help more deeply understand the pathogenesis of ONFH and may provide important clues for seeking more effective treatment strategies.

Network meta-analysis of invasive treatment for early-stage osteonecrosis of the femoral head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a common disabling disease in orthopedics. Blocking the progression of ONFH in the early stage is essential for avoiding total hip replacement.

PURPOSES

The purpose of this study is to evaluate the effect of invasive treatment on early-stage ONFH.

METHODS

According to the PRISMA guidelines, relevant English databases were searched in August 2022 to collect published research. Extract result indicators and conduct network meta-analysis using R software.

RESULTS

A total of 15 RCTs were included. All patients were diagnosed with early-stage ONFH. The surface under the cumulative ranking curve (SUCRA) showed that CD + BMMSC and CD + PRP were the most effective in improving HHS. The results of the league table showed that CD + BMMSC was superior to CD alone. Meanwhile, the SUCRA for FR showed that CD + BG + BMMSC was the most likely to be the most effective in reducing FR. The league table revealed that CD + BG, CD + BG + BMMSC, and CD + BMMSC were superior to CD alone, with statistically significant differences.

CONCLUSION

Considering the HHS and FR, CD + BMMSC may be the optimal treatment option to effectively delay the progression of ONFH and restore the postoperative function of patients.

REGISTRATION NUMBER

The study protocol has been registered on the PROSPERO platform (CRD42023380169).

No evidence of genetic causality between diabetes and osteonecrosis: a bidirectional two-sample Mendelian randomization analysis

OBJECTIVE

This study aimed to examine whether diabetes mellitus is causally associated with osteonecrosis.

METHOD

Using publicly accessible genome-wide association study statistics, a bidirectional two-sample Mendelian randomization analysis was carried out. In order to determine whether diabetes has a causal effect on osteonecrosis and whether osteonecrosis has a causal effect on diabetes, we extracted six date on diabetes in Europeans from IEU OpenGWAS and GWAS Catalogue and osteonecrosis in Europeans from FinnGen. We then evaluated the data using inverse variance weighting, MR-Egger regression, weighted median, weighted mode, and simple mode. The results' stability and dependability were then evaluated using sensitivity analysis and heterogeneity analysis. Finally, meta-analysis is used to further confirm if there is a relationship between diabetes and osteonecrosis.

RESULTS

When diabetes was used as an exposure factor, MR-Egger regression showed that directional fold product was unlikely to bias the results. Cochran's Q test showed only minor heterogeneity in a few data sets. Multidirectional tests Egger-intercept, MR-PRESSO and funnel plots for most data did not show multidirectional and asymmetry at the gene level. Most of the IVW results showed no causal relationship between diabetes mellitus and osteonecrosis. The results of meta-analysis of IVW methods further confirmed the absence of a causal relationship. Inverse MR analysis also showed no causal relationship between osteonecrosis and diabetes.

CONCLUSION

Results of bidirectional MR analysis show no evidence of causal relationship between diabetes and osteonecrosis.

Correlation between ESR1 and APOE gene polymorphisms and risk of osteonecrosis of the femoral head: a case-control study

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a disease with a high disability rate, and genetic factors are closely related to its pathogenesis. This study aimed to investigate the possible correlation between ESR1 and APOE gene polymorphisms and the risk of ONFH.

METHODS

In this case-control study, the potential association between three genetic variants (rs2982573 C < T, rs10872678 C < T, and rs9322332 A < C) of the ESR1 gene and two genetic variants (rs7259620 A < G and rs769446 C < T) of the APOE gene with the risk of ONFH was investigated. Correlations between gene polymorphisms and ONFH risk were assessed using logistic regression analysis, with calculation of odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The overall analysis demonstrated that rs9322332 in the ESR1 gene exhibited a correlation with a decreased risk of ONFH under the homozygous (AA vs.CC: OR = 0.69, 95% CI [0.53-0.90], p = 0.006), dominant (CA + AA vs. CC: OR = 0.70, 95% CI [0.54-0.90], p = 0.006), and additive (OR = 0.79, 95% CI [0.66-0.95], p = 0.013) models. The stratification analysis revealed that rs9322332 was linked to a lower risk of ONFH in subgroups characterized by individuals aged over 51 years and non-smokers. Nevertheless, there were no notable correlations found between ESR1 rs2982573 and rs10872678, as well as APOE rs7259620 and rs769446, with the risk of ONFH.

CONCLUSION

ESR1-rs9322332 is closely linked to a decreased risk of ONFH, thereby enhancing our understanding of the relationship between gene polymorphisms and ONFH.

Exploring the potential mechanism of Taohong Siwu decoction in the treatment of avascular necrosis of the femoral head based on network pharmacology and molecular docking

Based on network pharmacology and molecular docking, this study seeks to investigate the mechanism of Taohong Siwu decoction (THSWD) in the treatment of avascular necrosis of the femoral head (AVNFH). The Traditional Chinese Medicine Systems Pharmacology database was used in this investigation to obtain the active ingredients and related targets for each pharmaceutical constituent in THSWD. To find disease-related targets, the terms "avascular necrosis of the femoral head," "necrosis of the femoral head," "steroid-induced necrosis of the femoral head," "osteonecrosis," and "avascular necrosis of the bone" were searched in the databases DisGeNET, GeneCards, Comparative Toxicogenomics Database, and MalaCards. Following the identification of the overlap targets of THSWD and AVNFH, enrichment analysis using gene ontology, Kyoto Encyclopedia of Genes and Genomes, Reactome, and WikiPathways was conducted. The "THSWD-drug-active compound-intersection gene-hub gene-AVNFH" network and protein-protein interaction network were built using Cytoscape 3.9.1 and string, and CytoHubba was used to screen hub genes. The binding activities of hub gene targets and key components were confirmed by molecular docking. 152 prospective therapeutic gene targets were found in the bioinformatics study of ONFH treated with THSWD, including 38 major gene targets and 10 hub gene targets. The enrichment analysis of 38 key therapeutic targets showed that the biological process of gene ontology analysis mainly involved cytokine-mediated signaling pathway, angiogenesis, cellular response to reactive oxygen species, death-inducing signaling complex. The Kyoto Encyclopedia of Genes and Genomes signaling pathway mainly involves TNF signaling pathway, IL-17 signaling pathway, and the Recactome pathway mainly involves Signaling by Interleukins, Apoptosis, and Intrinsic Pathway for Apoptosis. WikiPathways signaling pathway mainly involves TNF-related weak inducer of apoptosis signaling pathway, IL-18 signaling pathway. According to the findings of enrichment analysis, THSWD cured AVNFH by regulating angiogenesis, cellular hypoxia, inflammation, senescence, apoptosis, cytokines, and cellular proliferation through the aforementioned targets and signaling pathways. The primary component of THSWD exhibits a strong binding force with the key protein of AVNFH. This study sheds new light on the biological mechanism of THSWD in treating AVNFH by revealing the multi-component, multi-target, and multi-pathway features and molecular docking mechanism of THSWD.

Comparative analysis of surgical interventions for osteonecrosis of the femoral head: a network meta-analysis of randomized controlled trials

BACKGROUND

Despite several surgical options, there remains no consensus regarding the optimal approach for osteonecrosis of the femoral head (ONFH), a prevalent and refractory disease. To determine the most suitable treatment modality, we compared randomized controlled trials (RCTs) that evaluated multiple surgical treatments for ONFH using a Bayesian network meta-analysis (NMA).

METHODS

The outcomes of 11 different surgical treatments were assessed using NMA comparisons of the rate of progression of femoral head necrosis, the rate of conversion to total hip arthroplasty, and improvement of the Harris hip score (HHS). A random effects model was used to analyze the odds ratio (OR) or mean difference, and risk of bias was assessed using the Cochrane risk of bias assessment tool for randomized trials. The confidence of the results was assessed using the confidence in network meta-analysis tool.

RESULTS

A total of 18 RCTs were included in the meta-analysis. Compared with core decompression (CD), the forest plot showed that autologous bone grafting (ABG), free fibula grafting (FFG), vascularized bone grafting (VBG), autologous bone grafting combined with bone marrow aspirate concentrate (ABG + BMAC), and biomaterial grafting combined with vascularized bone grafting (BMG + VBG) delayed ONFH progression. Among them, ABG + BMAC showed the most promising results (OR 0.019; 95% confidence interval [CI] 0.0012-0.25). However, upon comparing CD with different surgical modalities, no significant differences were found in preventing total hip arthroplasty. Furthermore, we cannot draw conclusions regarding the HHS due to attribution and high heterogeneity across the studies.

CONCLUSION

Overall, ABG, VBG, FFG, ABG + BMAC, and BMG + VBG showed significant results in preventing ONFH progression compared with that shown by CD. Based on the surface under the cumulative ranking, ABG + BMAC was the most effective. Moreover, all treatments involving bone grafting were found to be effective, possibly indicating the necessity of its use in the treatment of ONFH.

Systematic analysis of hip-preserving treatment for early osteonecrosis of the femoral head from the perspective of bibliometrics (2010-2023)

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a serious condition that causes bone tissue death, femoral head collapse, and hip joint destruction. Early intervention through hip-preserving treatment is crucial to slow down disease progression, preserve hip joint function, and improve the quality of life of patients. We analyzed the knowledge map, research gaps, and future research directions in the field of hip-preserving treatment for early ONFH.

METHODS

All publications related to hip-preserving treatment for early ONFH published between 2010 and 2023 were identified from the Web of Science Core Collection and analyzed using VOSviewer 1.6.19, CiteSpace 6.2.R2, and Scimago Graphica 1.0.35.

RESULTS

In total, 234 articles were analyzed. The results showed an exponential growth trend in the number of publications related to hip-preserving treatment for early ONFH in the past decade. China and the USA were the main contributors. International Orthopaedics published the most papers in this field, whereas Bone and Joint Surgery-American Volume had the highest average citation count per article. Several stable research topics were noted in this field, including core decompression (CD), osteotomy, bone transplantation in hip-preserving surgery, and cell therapy, which have become research hotspots in hip-preserving treatment.

CONCLUSIONS

Hip-preserving treatment for early ONFH has received increasing attention, and research in this field is expected to grow. Stable research topics include core decompression (CD), osteotomy, bone transplantation, and cell therapy. Future research is predicted to focus on cell therapy and combination therapy, resulting in an increasing number of publications on hip-preserving treatment for early ONFH.

Exosomes from bone marrow mesenchymal stem cells ameliorate glucocorticoid-induced osteonecrosis of femoral head by transferring microRNA-210 into bone microvascular endothelial cells

OBJECTIVES

Bone microvascular endothelial cells (BMECs) played an important role in the pathogenesis of glucocorticoid-induced osteonecrosis of femoral head (GCS-ONFH), and exosomes derived from bone marrow mesenchymal stem cells (BMSC-Exos) may provide an effective treatment. This study aimed to evaluate the effects of BMSC-Exos and internal microRNA-210-3p (miRNA-210) on GCS-ONFH in an in vitro hydrocortisone-induced BMECs injury model and an in vivo rat GCS-ONFH model.

METHODS

BMECs, BMSCs and BMSC-Exos were isolated and validated. BMECs after the treatment of hydrocortisone were cocultured with different concentrations of BMSC-Exos, then proliferation, migration, apoptosis and angiogenesis of BMECs were evaluated by CCK-8, Annexin V-FITC/PI, cell scratch and tube formation assays. BMSCs were transfected with miRNA-210 mimics and miRNA-210 inhibitors, then BMSC-ExosmiRNA-210 mimic and BMSC-ExosmiRNA-210 inhibitor secreted from such cells were collected. The differences between BMSC-Exos, BMSC-ExosmiRNA-210 mimic and BMSC-ExosmiRNA-210 inhibitor in protecting BMECs against GCS treatment were analyzed by methods mentioned above. Intramuscular injections of methylprednisolone were performed on Sprague-Dawley rats to establish an animal model of GCS-ONFH, then tail intravenous injections of BMSC-Exos, BMSC-ExosmiRNA-210 mimic or BMSC-ExosmiRNA-210 inhibitor were conducted after methylprednisolone injection. Histological and immunofluorescence staining and micro-CT were performed to evaluate the effects of BMSC-Exos and internal miRNA-210 on the in vivo GCS-ONFH model.

RESULTS

Different concentrations of BMSC-Exos, especially high concentration of BMSC-Exos, could enhance the proliferation, migration and angiogenesis ability and reduce the apoptosis rates of BMECs treated with GCS. Compared with BMSC-Exos, BMSC-ExosmiRNA-210 mimic could further enhance the proliferation, migration and angiogenesis ability and reduce the apoptosis rates of BMECs, while BMECs in the GCS + BMSC-ExosmiRNA-210 inhibitor group showed reduced proliferation, migration and angiogenesis ability and higher apoptosis rates. In the rat GCS-ONFH model, BMSC-Exos, especially BMSC-ExosmiRNA-210 mimic, could increase microvascular density and enhance bone remodeling of femoral heads.

CONCLUSIONS

BMSC-Exos containing miRNA-210 could serve as potential therapeutics for protecting BMECs and ameliorating the progression of GCS-ONFH.