Osteonecrosis of the Femoral Head

Bilateral avascular necrosis: A rare complication of Fabry disease

Fabry disease is a rare X-linked lysosomal storage disorder caused by pathogenic variants in the GLA gene, which encodes for the α-galactosidase A enzyme responsible for degrading globotriaosylceramide. Its deficiency leads to the accumulation of GL3 in lysosomes, resulting in progressive multi-organ involvement, with predilection for the heart and kidneys. Clinical features associated with Fabry disease include acroparesthesia, angiokeratomas, hypohidrosis, corneal whorls, chronic kidney disease, cardiomyopathy, and strokes. Osteopenia and osteoporosis are less known complications, with rare reported cases of avascular necrosis of the hips. We report bilateral avascular necrosis in a 40-year-old-man diagnosed with Fabry at the age of 25 years. He carriers the familiar p.G328V GLA pathogenic variant. His Fabry features includes acroparesthesia, angiokeratomas, hypohidrosis, temperature and exercise intolerance, pain crises, abdominal pain and diarrhea, tinnitus, hearing loss, hypertrophic cardiomyopathy, palpitations, and chest pain. Family history reveals Fabry disease affecting multiple maternal relatives. The patient was recently diagnosed with avascular necrosis of the right hip requiring total arthroplasty due to failure of conservative treatment. Nine months later, he developed left hip pain attributed to avascular necrosis, also treated with total arthroplasty. This case highlights a rare skeletal complication of Fabry disease, underscoring the need for early diagnosis, optimizing treatment of Fabry disease, managing atypical comorbidities, and vigilant monitoring of bone health.

Utilizing bioinformatics to identify biomarkers and analyze their expression in relation to immune cell ratios in femoral head necrosis

Background

Necrosis of the Femoral Head (NFH) represents a challenging orthopedic condition, characterized by elusive early detection and rapid progression, predominantly in the middle-aged demographic. Current research on the pathophysiological and immunoregulatory mechanisms underpinning immune cell infiltration in NFH is sparse. This study employs bioinformatics analysis of publicly available RNA sequencing databases to elucidate the pivotal molecules and pathways implicated in NFH progression.

Methods

The NFH-related dataset GSE123568 was obtained from the Gene Expression Omnibus (GEO). Subsequently, CIBERSORT was utilized to assess the proportion and distribution of immune cell types, followed by the identification of critical Hub immune cells using LASSO and RFE algorithms. The dataset GSE123568 was then explored to identify significantly differentially expressed genes (DEGs). These genes were further refined by intersecting with death-associated genes reported in existing literature. GO and KEGG pathway enrichment analyses were conducted to elucidate their underlying molecular mechanism. A protein-protein interaction (PPI) network was constructed using the STRING database and visualized via Cytoscape. Hub genes were identified using the CytoHubba plugin, followed by enrichment analysis, and their expression levels were evaluated using the ROC curve. In addition, we performed expression data visualization and ROC curve analysis on the external dataset GSE74089 to further evaluate the discriminative power of the hub genes. Moreover, the study analyzed the correlation between the identified hub genes and Hub immune cells. Finally, we verified the hub genes utilizing real-time fluorescence quantitative polymerase chain reaction (RT-qPCR) and immunohistochemistry.

Results

Four types of immune cells (Neutrophil, Mast cell resting, Myeloid dendritic cell activated, Macrophage M0) were identified. Fourteen pivotal genes (BCL2L1, BIRC2, NFKBIA, XIAP, CFLAR, AKT1, BIRC3, IKBKB, RIPK1, CASP8, TNFRSF1A, IL1B, CASP1, STAT3) were identified, and the findings were validated using the external dataset GSE74089. Among these, STAT3 exhibited the most pronounced positive correlation with neutrophils (r = 0.6804, p = 3.525e-05). Conversely, XIAP displayed the most significant negative correlation with Myeloid dendritic cell activated (r = -0.3610, p = 0.04003). In experiments, the experimental outcomes for five hub genes (CASP8, TNFRSF1A, AKT1, XIAP and STAT3) were congruent with the results obtained from bioinformatics analysis.

Conclusion

Our study identified CASP8, TNFRSF1A, AKT1, XIAP, STAT3 and BCL2L1 as potential biomarkers for NFH patients and elucidated the immune cell types with the strongest association to these markers. These insights may be crucial for the early diagnosis, understanding of the pathophysiological mechanisms, and the development of treatment strategies for NFH.

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.

The role of the PKCζ/JNK signaling pathway in regulating the development of femoral head necrosis

Osteonecrosis of the femoral head (ONFH) is a debilitating condition characterized by the death of bone cells in the hip joint, resulting in profound disability. This condition has a significant global prevalence. Glucocorticoid (GC)-induced apoptosis of bone cells serves as a crucial cellular mechanism underlying ONFH. The protein kinase C zeta (PKCζ) and c-Jun N-terminal kinase (JNK)/c-Jun cascades have been implicated in the progression of ONFH, yet their interrelationship and contributions to disease development remain unclear. The objective of this study was to investigate the combined impact of PKCζ and JNK/c-Jun signaling on dexamethasone (Dex)-induced apoptosis in osteoblasts in vitro and in GC-induced ONFH rat models in vivo. In vitro experiments were conducted using hFOB1.19 osteoblastic cells to scrutinize the effects of Dex-induced apoptosis. The role of the PKCζ/JNK/c-Jun signaling pathway in this process was examined using naringenin-7-O-β-D-Glucuronide (N7G), a PKC inhibitor, and anisomycin, a JNK activator. The findings were further validated using a rat model of ONFH in vivo. Our results revealed that PKCζ activation augmented JNK/c-Jun signaling and facilitated Dex-induced osteoblast apoptosis. Inhibition of PKCζ with N7G mitigated these effects, while JNK activation with anisomycin intensified them. Similar regulatory effects on osteoblast apoptosis and ONFH progression were observed in the in vivo rat models. Glucocorticoids can induce osteoblast apoptosis and contribute to the development of ONFH by activating the PKCζ/JNK/c-Jun signaling pathway. This study provides compelling evidence supporting the potential therapeutic value of comprehending the pathogenesis of ONFH and developing targeted treatments for this debilitating condition.

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.

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.

Functional and HIP survivorship outcomes of free Vascularized fibula graft in the management of post COVID-19 Osteonecrosis of femur head: A prospective case series

Aim & objectives

To evaluate functional and radiological outcomes of Free Vascularized Fibula grafting in management of Covid-19 associated Osteonecrosis of Femur Head.

Design

Prospective Case Series.

Methods

14 hips (10 patients) with ONFH following COVID-19 were treated with Free Vascularized Fibula graft from June 2021 to December 2022 and were subsequently evaluated monthly for 6 months and then every 3 months post operatively for functionality (Harris Hip Score), Femur head collapse and related complications.

Results

Mean age of patients was 29.3 years (Range: 20-38 years). 14 diseased hips were classified on the basis of Steinberg classification as 4 stage 2B, 4 stage 3B and 6 stage 3C. The average follow up period was 2.1 years (Range: 12 months-34 months).Eight of fourteen hips survived and six progressed to collapse. Mean HHS at final follow-up was 68.3 in comparison to 65.8 pre-operatively. 4 fair and 4 poor HH scores were converted to 4 excellent and 4 good scores post-operatively.Two late complications were noted-one FHL contracture and one CPN neuroma.

Conclusion

Free Vascularized Fibula Graft, as a hip salvage modality, showed optimal results in the treatment of COVID-19 related ONFH, which is associated with aggressive disease course and extensive involvement of femur head.

Risk of avascular necrosis in patients with inflammatory bowel disease: Insights from a nationwide cohort study and the impact of corticosteroid use

BACKGROUND AND AIM

Corticosteroid use is a risk factor for avascular necrosis (AVN) and inflammatory bowel disease (IBD) patients are often exposed to higher corticosteroid usage. We investigated the epidemiology and risk factors of AVN in a nationwide population-based cohort of IBD patients.

METHODS

Patients newly diagnosed with IBD were identified, and sex- and age-matched participants from the general population were selected in a 1:3 IBD:non-IBD ratio. We investigated newly diagnosed AVN and assessed the incidence rates and risk of AVN with multivariate Cox regression models.

RESULTS

During the median follow-up period of 7.22±3.85 years, 357 (0.62 %) were newly diagnosed with AVN. The risk of AVN was higher in IBD (aHR = 1.42, 95 % CI: 1.25-1.62). Ulcerative colitis (UC) patients showed a particularly elevated risk of developing AVN. IBD patients with higher cumulative corticosteroid intake and exposed to a mean prednisolone-equivalent daily dose>20 mg for >1 month were at higher risk of AVN. In Crohn's disease (CD), longer exposure time to >20 mg prednisolone-equivalent presented a trend in increased risk.

CONCLUSION

AVN risk was higher in IBD than in those without, particularly in UC and corticosteroid use in IBD could pose a crucial role. These underscore the importance of considering the AVN etiological factors, particularly corticosteroid use.

Mechanism of action of Salvia miltiorrhiza on avascular necrosis of the femoral head determined by integrated network pharmacology and molecular dynamics simulation

Avascular necrosis of the femoral head (ANFH) is a progressive, multifactorial, and challenging clinical condition that often leads to hip dysfunction and deterioration. The pathogenesis of ANFH is complex, and there is no foolproof treatment strategy. Although some pharmacologic and surgical treatments have been shown to improve ANFH, the associated side effects and poor prognosis are of concern. Therefore, there is an urgent need to explore therapeutic interventions with superior efficacy and safety to improve the quality of life of patients with ANFH. Salvia miltiorrhiza (SM), a traditional Chinese medicine with a long history, is widely used for the treatment of cardiovascular and musculoskeletal diseases due to its multiple pharmacological activities. However, the molecular mechanism of SM for the treatment of ANFH is still unclear. Therefore, this study aimed to explore the potential targets and mechanisms of SM for the treatment of ANFH using network pharmacology and molecular modeling techniques. By searching multiple databases, we screened 52 compounds and 42 common targets involved in ANFH therapy and identified dan-shexinkum d, cryptotanshinone, tanshinone iia, and dihydrotanshinlactone as key compounds. Based on the protein-protein interaction (PPI) network, TP53, AKT1, EGFR, STAT3, BCL2, IL6, and TNF were identified as core targets. Subsequent enrichment analysis revealed that these targets were mainly enriched in the AGE-RAGE, IL-17, and TNF pathways, which were mainly associated with inflammatory responses, apoptosis, and oxidative stress. In addition, molecular docking and 100 nanoseconds molecular dynamics (MD) simulations showed that the bioactive compounds of SM had excellent affinity and binding strength to the core targets. Among them, dan-shexinkum d possessed the lowest binding free energy (-215.874 kcal/mol and - 140.277 kcal/mol, respectively) for AKT1 and EGFR. These results demonstrated the multi-component, multi-target, and multi-pathway intervention mechanism of SM in the treatment of ANFH, which provided theoretical basis and clues for further experimental validation and development of anti-ANFH drugs.

Angiogenesis of Avascular Necrosis of the Femoral Head: A Classic Treatment Strategy

Avascular necrosis of the femoral head (ANFH) is a type of osteonecrosis due to the cessation of blood supply, characterized by persistent local pain and collapse of the joint. The etiology of ANFH is multifaceted, and while its precise pathogenesis remains elusive, it is currently widely believed that the femoral head is highly dependent on the vascular system. A large number of studies have shown that vascular injury is the initial factor in the onset of ANFH. In this review, we briefly introduced the process of angiogenesis and the blood supply to the femoral head, with a focus on summarizing the existing research on promoting angiogenesis for the treatment of ANFH. We conclude that providing alternative pathways through angiogenesis to resolve the problem of the obstructed free flow of the blood is an important means of treating ANFH. Moreover, we also looked forward to the mechanism of endothelial metabolism, which has not yet been studied in femoral head necrosis models, providing potential strategies for more effective use of angiogenesis for the treatment of femoral head necrosis.

Potential molecular targets for the pharmacologic management of non-traumatic osteonecrosis

INTRODUCTION

Non-traumatic osteonecrosis is a debilitating condition marked by bone death, primarily due to reduced blood supply. Currently, no effective pharmacologic intervention is available to manage this condition effectively.

AREAS COVERED

Lipid metabolic disorders, chronic inflammation, vascular dysfunction, coagulopathy, and impaired bone homeostasis are suggested as the key pathogenic mechanisms involved in the development of non-traumatic osteonecrosis. Targeting any of these dysfunctions offers a potential avenue for pharmacologic intervention. However, the potential molecular targets for pharmacologic treatment of non-traumatic osteonecrosis remain underexplored. In this study, we reviewed available databases to compile a comprehensive set of pathogenic mechanisms and corresponding therapeutic targets for non-traumatic osteonecrosis.

EXPERT OPINION

Evidence suggests that a single pathogenic mechanism cannot fully explain the development of osteonecrosis, supporting the adoption of a multi-pathogenic theory. This theory implies that effective management of non-traumatic osteonecrosis requires targeting multiple pathogenic mechanisms simultaneously. Moreover, the same pathogenic mechanisms are unlikely to explain osteonecrosis development in patients with different etiologies. Consequently, a one-size-fits-all approach to medication is unlikely to be effective across all types of non-traumatic osteonecrosis. Future research should, therefore, focus on developing multi-target pharmacologic treatments tailored to the specific etiology of non-traumatic osteonecrosis.

The Multiplicative Effects of Individual Risk Factors in the Development of Osteonecrosis of the Femoral Head

BACKGROUND

While individual risk factors, including chronic corticosteroid use, alcohol abuse, and smoking, are implicated in osteonecrosis of the femoral head (ONFH), the degree to which multiple risk factors increase risk is unknown. This study aimed to: (1) identify the demographic characteristics of patients who have ONFH; (2) quantify the effects of individual risk factors on ONFH development; (3) quantify the effects of combined risk factors on ONFH development; and (4) determine the prognostic implications of combined risk factors on ONFH development.

METHODS

This was a retrospective cohort study. A national insurance database was used to study a population of 2,612,383 adult patients who had a 10-year follow-up period. There were 10,233 patients identified who had a diagnosis of ONFH. We identified patients who had chronic corticosteroid use, tobacco use, and/or alcohol abuse and assessed the risk of developing ONFH over a 10-year period. Patients who had individual and multiple risk factors were grouped for comparison, and Chi-square analyses were performed.

RESULTS

Higher proportions of patients who had each individual risk factor developed ONFH compared to proportions of patients who did not have risk factors. Patients who had combined risk factors were at greater risk of developing ONFH compared to patients who had no risk factors and those who had single risk factors. Combined risk factors demonstrated multiplicative effects on the development of ONFH: tobacco-alcohol risk ratio (RR) 5.25, corticosteroid-alcohol RR 10.20, tobacco-corticosteroid RR 8.69, and corticosteroid-tobacco-alcohol RR 12.54. Patients who had combined risk factors developed ONFH at younger ages than those who had single risk factors. Kaplan-Meier curve analyses demonstrated worse 10-year hip survival in the setting of combined risk factors.

CONCLUSIONS

Combined risk factors have a multiplicative effect on the risk of developing of atraumatic ONFH. Orthopaedic surgeons may care for at-risk individuals through modulation of risk factors.

LEVEL OF EVIDENCE

Retrospective Cohort Study, Level III.

Aseptic Osteonecrosis of the Femoral Head: The Effect of Corticosteroid Therapy and Long COVID Syndrome

SARS‑CoV‑2 infection remains a hot topic; it is characterized by its multi-systemic involvement. Corticosteroid intake has been the subject of worldwide attention as a potentially effective treatment against coronavirus disease 2019 (COVID-19). Corticosteroids are registered on the WHO list of essential medicines, easily accessible for a low price, and particularly useful for different categories of people. The authors highlight the impact of corticosteroid administration for COVID-19 treatment on the occurrence of aseptic osteonecrosis in the femoral head. They also examine the pace of onset in comparison to corticosteroid usage unrelated to COVID-19. This article presents a patient with osteonecrosis of the femoral head after taking corticosteroid therapy in the treatment of COVID-19. The dose taken by the patient is 90 mg of dexamethasone equivalent to 600 mg of prednisone. The patient experienced the onset of OTA, and the duration of development was three months, indicating a relatively brief period. Comparison was made with data from the literature from 6 months to 1 year after taking corticosteroids in a context outside of COVID-19.

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).

Efficacy and risk factors for anxiety and depression after mini-incision hip arthroplasty for femoral head osteonecrosis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a prevalent orthopedic issue, leading to the collapse and fragmentation of the femoral head in its advanced stages, which can severely impair patients' quality of life. Total hip arthroplasty (THA) is a clinical intervention frequently used to alleviate ONFH symptoms and reinstate hip functionality. The conventional surgical technique is invasive and comes with an extended recuperation period, posing significant challenges for patients. With the progression of medical technology, the use of the mini-incision technique in minimally invasive THA (MITHA) has become more prevalent. However, comparative studies examining the effectiveness of these two surgical procedures in treating ONFH remain scarce. Furthermore, understanding patients' psychological well-being is crucial given its profound influence on postoperative recuperation.

AIM

To evaluate the impact of mini-incision MITHA on ONFH treatment and to identify the risk factors associated with postoperative anxiety and depression.

METHODS

A retrospective study was conducted on 125 patients treated for ONFH at Xi'an Hong Hui Hospital between February 2020 and January 2022, with the term "consecutive" indicating that these patients were treated in an unbroken sequence without any selection. Among these, 60 patients (control group) underwent traditional THA, while 65 patients (observation group) were treated with mini-incision MITHA. Variations in the visual analog scale (VAS) score and the Harris hip score were monitored. Additionally, shifts in pre- and posttreatment Hamilton anxiety (HAMA) and Hamilton depression (HAMD) scale scores were recorded. Patients with both postoperative HAMA and HAMD scores of ≥ 8 were identified as those experiencing negative emotions. Logistic regression was utilized to analyze the determinants influencing these negative emotional outcomes. Comparative analyses of surgical and postoperative metrics between the two groups were also conducted.

RESULTS

Posttreatment results indicated a significantly higher VAS score in the control group than in the observation group, while the Harris score was considerably lower (P < 0.0001). The observation group benefited from a notably shorter operation duration, reduced blood loss, diminished incision size, and a decreased postoperative drainage time (P < 0.0001), accompanied by a reduced hospital stay and lower treatment costs (P < 0.0001). The control group had elevated posttreatment HAMA and HAMD scores in comparison to the observation group (P < 0.0001). Multivariate logistic regression revealed that being female [odds ratio (OR): 4.394, 95%CI: 1.689-11.433, P = 0.002], having a higher postoperative VAS score (OR: 5.533, 95%CI: 2.210-13.848, P < 0.0001), and having higher treatment costs (OR: 7.306, 95%CI: 2.801-19.057, P < 0.0001) were significant independent determinants influencing postoperative mood disturbances.

CONCLUSION

Compared to conventional THA, mini-incision MITHA offers advantages such as reduced operation time, minimal bleeding, and a shorter incision in ONFH patients. Moreover, factors such as sex, postoperative pain (reflected in the VAS score), and treatment costs significantly impact postoperative anxiety and depression.

Bone marrow edema of the hip: a narrative review

Bone marrow edema (BME) of the hip is a radiological-clinical condition with symptoms ranging from asymptomatic to severe, and it is characterized by increased interstitial fluid within the bone marrow, usually at the femur. Depending on the etiology it can be classified as primary or secondary. The primary cause of BME is unknown, while the secondary forms include traumatic, degenerative, inflammatory, vascular, infectious, metabolic, iatrogenic, and neoplastic etiologies. BME could be classified as reversible or progressive. Reversible forms include transient BME syndrome and regional migratory BME syndrome. Progressive forms include avascular necrosis of the femoral head (AVNH), subchondral insufficiency fracture, and hip degenerative arthritis. The diagnosis can be difficult, because at the beginning, the outbreak of hip pain, typically acute and disabling without any prior trauma or exceptional physical activity, is poorly supported by radiographic findings. MRI is the gold standard, and it shows an area of intermediate signal on T1-weighted MRI scans and a high signal on T2-weighted scans, usually lacking sharps margins. In the reversible form, BME is typically self-limiting, and it can be managed conservatively by means of pharmacological and physical therapy. Surgery is generally required for progressive forms in patients who failed non-operative treatment, and it ranges from femoral head and neck core decompression to total hip arthroplasty.

Decreased serum 4-Hydroxynonenal level as a biomarker for the progression of steroid-induced osteonecrosis of the femoral head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is becoming a prevalent global health problem. 4-Hydroxynonenal (4-HNE) serves as a common marker of oxidative stress. This study aims to study the potential role of 4-HNE in the progression of steroid-induced osteonecrosis of the femoral head (SIONFH).

METHOD

Between April 2021 and December 2021, 64 subjects were enrolled in this cross-sectional case‒control study. Thirty-six patients were grouped based on the Association Research Circulation Osseous (ARCO) classification, and 28 healthy volunteers without hip pain or any lesions shown in anteroposterior and frog-leg lateral pelvic radiographs served as the normal control group. Bone hematoxylin-eosin (HE) staining, microcomputed tomography (micro-CT), immunohistochemistry, and levels of plasma 4-HNE were evaluated.

RESULTS

The 4-HNE level was higher in the SIONFH group than in the normal control group (P < 0.001), and 4-HNE levels were significantly higher in SIONFH patients in the early stage of disease (stage II). The 4-HNE level was negatively correlated with ARCO stage (r = - 0.6875, P < 0.001). Immunohistochemistry revealed the presence of 4-HNE in the trabecular bone, osteocytes, and bone marrow.

CONCLUSION

The 4-HNE level is negatively associated with ARCO stages. Lower levels of 4-HNE may serve as a critical biomarker for the progression of SIONFH.

Experimental study of a 3D-printing technique combined with biphasic calcium phosphates to treat osteonecrosis of the femoral head in a canine model

OBJECTIVE

This study was aimed to use a digital design of 3D-printing technology to create a surgical navigation template. At the same time, biphasic calcium phosphate (BCP) was applied to treat osteonecrosis of the femoral head (ONFH) in animal models, based on accurate positioning of necrotic lesions in the navigation templates and observation of its therapeutic effect.

METHODS

Fifteen healthy adult male and female beagle dogs weighing 20 + 2 kg were randomly divided into three groups (n = 5) after establishing a model of ONFH using the liquid nitrogen freezing method. Each model underwent necrotic lesion creation and BPC implantations on one side of the femoral head and only necrotic lesion creation on the other side of the femoral head. Each group underwent CT examination, gross observation, histological examination and immunohistochemical staining at 6 weeks, 12 weeks and 18 weeks postoperatively.

RESULTS

At weeks 6, 12, and 18, CT and gross examination showed that the necrotic area in the experimental group was basically intact and had been completely raised by BCP material. In the control group, there were signs of bone repair in the femoral head, but there were still large bone defects and cavities. At week 18, extensive collapse of the cartilage surface was observed. Through histological examination, in the experimental group at 12 and 18 weeks, a large number of new and reconstructed bone trabeculae containing a large amount of collagen fibres were observed (P < 0.05), while in the control group, there was extensive necrosis of the bone trabeculae without cellular structural areas. Immunohistochemical examination observation: A large number of CD31-positive cells were observed in the experimental group at 6 weeks, gradually decreasing at 12 and 18 weeks (P < 0.05), while a small number of CD31-positive cells were observed in the control group at 18 weeks.

CONCLUSION

The 3D-printed navigation template can accurately locate ONFH lesions. Implantation of BCP material can effectively play a supporting role, prevent the collapse of the loading surface, and induce bone formation and angiogenesis to some extent.

Increasing trend toward joint-preserving procedures for hip osteonecrosis in the United States from 2010 to 2019

INTRODUCTION

The incidence of osteonecrosis of the femoral head is estimated at about 10 to 20,000 patients annually, and, when left untreated, 80% or more of cases progress to femoral head collapse. A series of joint-preserving procedures have been developed to prevent/delay the need for hip arthroplasty. The aim of this study was to provide a five-year update: (1) evaluating temporal trends of arthroplasty vs. joint-preservation techniques such as core decompression, bone grafting, osteotomies, and arthroscopy; (2) determining proportions of procedures in patients aged less than vs. over 50 years; and (3) quantifying rates of specific operative techniques.

METHODS

A total of 10,334 patients diagnosed with osteonecrosis of the femoral head and having received hip surgery were identified from a nationwide database between 1 January 2010 and 31 December 2019, by using the International Classification of Disease, the Ninth/Tenth revision (ICD-9/10) codes. The percentage of patients managed by each operative procedure was calculated annually. To identify trends, patients were grouped by age under/over 50 years and divided into a joint-preserving and a non-joint-preserving (arthroplasty) group. Chi-squared tests were performed to compare the total number of procedures per year.

RESULTS

Rates of arthroplasty far exceeded those for joint-preserving procedures. However, from 2015 to 2019, significantly more joint-preserving procedures were performed than in 2010 to 2014 (4.3% vs. 3.0%, P < 0.001). Significantly more joint-preserving procedures were performed in patients aged < 50 years relative to those ≥ 50 years (7.56% vs. 1.86%, P < 0.001). Overall, total hip arthroplasty was the most common procedure (9,814; 94.97%) relative to core decompression (331; 3.20%), hemiarthroplasty/resurfacing (102; 0.99%), bone grafting (48; 0.46%), and osteotomy (5; 0.05%).

CONCLUSION

Management of patients who have osteonecrosis of the femoral head continues to be predominantly arthroplasty procedures, specifically, total hip arthroplasty. Our findings suggest a small, but significant trend toward increased joint-preserving procedures, especially in patients under 50 years. In particular, the proportion of patients receiving core decompression has increased significantly from 2015 to 2019 relative to prior years.

Trends in Surgical Management of Osteonecrosis of the Femoral Head: A 2010 to 2020 Nationwide Study

BACKGROUND

The incidence of osteonecrosis of the femoral head (ONFH) is estimated at more than 20,000 patients annually in the US. Our study aimed to provide a 10-year analysis: 1) evaluating total operative procedures with rates normalized to the population; 2) determining trends of arthroplasty versus joint-preserving procedures; and 3) quantifying specific operative techniques in patients <50 versus >50 years of age.

METHODS

A total of 64,739 patients who were diagnosed with ONFH and underwent hip surgery were identified from a nationwide database between 2010 and 2020. The percentage of patients managed by each operative procedure was calculated and normalized to the overall population annually. Patients were grouped into joint-preserving versus non-joint-preserving (arthroplasty) procedures, and divided by age under/over 50 years. Linear regression modeling was performed to evaluate trends/differences in procedural volume by year.

RESULTS

The number of operative procedures to treat ONFH has relatively declined from 2010 to 2020. The relative proportion of joint-preserving procedures increased (8.6% to 11.2%) during this time period. There were significantly more joint-preserving procedures in patients aged <50 years relative to >50 years (15.3% versus 2.7%, P < .001). Overall, THA was the most common procedure (57,033;88.1%) relative to hemiarthroplasty (3,875;6.0%), core decompression (2,730;4.2%), bone graft (467;0.7%), and osteotomy (257;0.4%).

CONCLUSION

Surgical management of patients who have ONFH remains predominantly arthroplasty procedures (94% overall). Our findings suggest an increase in joint-preserving procedures, particularly core decompression, in patients <50 years (15.3%). Our findings provide insight into surgical management trends for ONFH, and suggest opportunities for joint-preserving procedures.

Macrophage migration inhibitory factor protects bone marrow mesenchymal stem cells from hypoxia/ischemia-induced apoptosis by regulating lncRNA MEG3

OBJECTIVES

This research was performed to explore the effect of macrophage migration inhibitory factor (MIF) on the apoptosis of bone marrow mesenchymal stem cells (BMSCs) in ischemia and hypoxia environments.

METHODS

The cell viability of BMSCs incubated under hypoxia/ischemia (H/I) conditions with or without pretreatment with MIF or triglycidyl isocyanurate (TGIC) was detected using cell counting kit-8 (CCK-8) analysis. Plasmids containing long noncoding RNA (lncRNA) maternally expressed gene 3 (MEG3) or β-catenin small interfering RNA (siRNA) were used to overexpress or downregulate the corresponding gene, and the p53 signaling pathway was activated by pretreatment with TGIC. The influences of MIF, overexpression of lncRNA MEG3, activation of the p53 signaling pathway, and silencing of β-catenin on H/I-induced apoptosis of BMSCs were revealed by western blotting, flow cytometry, and terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) staining.

RESULTS

From the results of CCK-8 assay, western blotting, and flow cytometry, pretreatment with MIF significantly decreased the H/I-induced apoptosis of BMSCs. This effect was inhibited when lncRNA MEG3 was overexpressed by plasmids containing MEG3. The p53 signaling pathway was activated by TGIC, and β-catenin was silenced by siRNA. From western blot results, the expression levels of β-catenin in the nucleus and phosphorylated p53 (p-p53) were downregulated and upregulated, respectively, when the lncRNA MEG3 was overexpressed. Through flow cytometry, MIF was also shown to significantly alleviate the increased reactive oxygen species (ROS) level of BMSCs caused by H/I.

CONCLUSIONS

In summary, we conclude that MIF protected BMSCs from H/I-induced apoptosis by downregulating the lncRNA MEG3/p53 signaling pathway, activating the Wnt/β-catenin signaling pathway, and decreasing ROS levels.

Autologous Marrow Mesenchymal Stem Cell Driving Bone Regeneration in a Rabbit Model of Femoral Head Osteonecrosis

Osteonecrosis of the femoral head (ONFH) is a progressive degenerative disease that ultimately requires a total hip replacement. Mesenchymal stromal/stem cells (MSCs), particularly the ones isolated from bone marrow (BM), could be promising tools to restore bone tissue in ONFH. Here, we established a rabbit model to mimic the pathogenic features of human ONFH and to challenge an autologous MSC-based treatment. ON has been originally induced by the synergic combination of surgery and steroid administration. Autologous BM-MSCs were then implanted in the FH, aiming to restore the damaged tissue. Histological analyses confirmed bone formation in the BM-MSC treated rabbit femurs but not in the controls. In addition, the model also allowed investigations on BM-MSCs isolated before (ON-BM-MSCs) and after (ON+BM-MSCs) ON induction to dissect the impact of ON damage on MSC behavior in an affected microenvironment, accounting for those clinical approaches foreseeing MSCs generally isolated from affected patients. BM-MSCs, isolated before and after ON induction, revealed similar growth rates, immunophenotypic profiles, and differentiation abilities regardless of the ON. Our data support the use of ON+BM-MSCs as a promising autologous therapeutic tool to treat ON, paving the way for a more consolidated use into the clinical settings.