Sustained hemostatic abnormality in patients with steroid-induced osteonecrosis in the early period after high-dose corticosteroid therapy

Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head

PURPOSE

The Clinical Practice Guidelines for Osteonecrosis of the Femoral Head (ONFH) 2019 Edition, written by the working group for ONFH guidelines of the Japanese Investigation Committee (JIC) for ONFH under the auspices of the Japanese Ministry of Health, Labour, and Welfare and endorsed by the Japanese Orthopaedic Association, were published in Japanese in October 2019. The objective of this guideline is to provide a support tool for decision-making between doctors and patients.

METHODS

Procedures for developing this guideline were based on the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014, which proposed an appropriate method for preparing clinical guidelines in Japan.

RESULTS

This clinical practice guideline consists of 7 chapters: epidemiology; pathology; diagnosis; conservative therapy; surgical treatment: bone transplantation/cell therapy; surgical treatment: osteotomy; and surgical treatment: hip replacement. Twelve background questions and 13 clinical questions were determined to define the basic features of the disease and to be addressed when deciding treatment in daily practice, respectively.

CONCLUSIONS

The clinical practice guidelines for the ONFH 2019 edition will be useful for physicians, investigators, and medical staff in clinical practice, as well as for patients, during the decision-making process when defining how to treat ONFH.

Avascular necrosis of the femoral head in patients treated for leukaemia. Assessment of the need for a diagnostic protocol

OBJECTIVE

To evaluate the incidence of avascular necrosis of the hip in leukaemia patients treated in our hospital with high doses of corticosteroids in order to evaluate the necessity for an early detection protocol.

MATERIAL AND METHODS

Observational-descriptive and retrospective study from 2005 to 2016 of 253 patients diagnosed with paediatric leukaemia. Patients with musculoskeletal pathology were identified and patients with avascular necrosis were analysed.

RESULTS

A total of 26 patients (10%) had musculoskeletal symptoms. Three patients with avascular necrosis (1.2%) were analysed. One girl, 7 years old, was treated conservatively with traction - suspension and discharge. Two boys, an 11 and a 15.4 year-old,who developed graft-versus-host disease secondary to bone marrow transplantation, and whose treatment included high doses of corticosteroids, developed avascular necrosis of the hip. One was treated with bisphosphonates and forage and the other ended up with a total hip arthroplasty.

DISCUSSION

The occurrence of musculoskeletal symptoms during the treatment of leukaemia is different according to the bibliographic series (0.43 -12.6%). Some authors observe an increased risk in female patients between the ages of 10 and 17. A retrospective study reveals that there is a delay of 3.9 months in the diagnosis of CAP since the onset of pain. Other authors relate NAV to loading joints, age and high doses of corticosteroids.

CONCLUSION

Based on the low incidence of avascular necrosis of the hip in our 14-year-old population treated for leukaemia, the creation of diagnostic protocols seems not to be necessary. However, close monitoring of patients with potential risk factors recognized in the literature, is advisable.

Role of coagulopathy in glucocorticoid-induced osteonecrosis of the femoral head

The two major theories of glucocorticoid (GC)-induced osteonecrosis of the femoral head (ONFH) are apoptosis and ischaemia. The traditional theory implicates ischaemia as the main aetiological factor because the final common pathway of ONFH is interruption of blood supply to the bone. The most common causes of interruption of blood supply include fat embolism and coagulation disorders. GCs can directly or indirectly lead to coagulation disorders, producing a hypercoagulable state, followed by poor blood flow, ischaemia, and eventually ONFH. This review summarizes the existing knowledge on coagulation disorders in the context of GC-induced ONFH, including hypofibrinolysis and thrombophilia, endothelial cell dysfunction and damage, endothelial cell apoptosis, lipid metabolism, platelet activation, and the effect of anticoagulant treatment.

High triglyceride is a risk factor for silent osteonecrosis of the femoral head in systemic lupus erythematosus

The purpose of this study was to clarify the factors related to silent osteonecrosis of the femoral head (ONFH) in patients with systemic lupus erythematosus (SLE). Seventy-eight patients with SLE were selected on the basis of having been newly diagnosed and requiring high-dose prednisolone, including pulse therapy with methylprednisolone, as the initial treatment. All the patients initially underwent MRI at 3 months after the start of corticosteroid treatment to detect any early changes in the femoral head. These examinations were then performed again 3 months later. Laboratory parameters were evaluated at the start of steroid treatment and at 1 month thereafter. By 3 months after the start of corticosteroid treatment, silent ONFH was diagnosed by MRI in 21 patients (26.9 %), being bilateral in 11 patients and unilateral in 10. The occurrence of silent ONFH was not related to SLE disease activity index, serological activity, or renal function; it was also unrelated to body mass index (BMI), body surface area (BSA), and the initial dose of prednisolone per unit body weight. However, the total cholesterol level at 4 weeks after the start of steroid treatment tended to be higher in patients with silent ONFH. Patients with a higher triglyceride level showed a significantly higher frequency of silent ONFH both before (p = 0.002) and 4 weeks after (p = 0.036) steroid initiation.A high triglyceride level is an important risk factor for silent ONFH in patients with SLE, and large-scale epidemiologic surveys of such early events are needed in this patient population.

Management of femoral head osteonecrosis: Current concepts

Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.

Coagulation abnormalities in osteonecrosis and bone marrow edema syndrome

The aim of this review was to provide information about the variety of thrombophilic and hypofibrinolytic markers that are possible risk factors for the development of osteonecrosis and bone marrow edema syndrome. A total of 48 parameters were identified in 45 studies that included 2163 patients. The most frequently reported laboratory findings included altered serum concentrations of lipoproteins, decreased concentration and function of fibrinolytic agents, increased levels of thrombophilic markers, and several single nucleotide polymorphisms. Despite inhomogeneities in reported parameters, results, patients' collectives, and treatment strategies, these data suggest that coagulation abnormalities may play an important role in the emergence of osteonecrosis and bone marrow edema syndrome.

Incidence of osteonecrosis associated with corticosteroid therapy among different underlying diseases: prospective MRI study

OBJECTIVES

The purpose of this study was to clarify the incidence of (CS)-associated osteonecrosis among different underlying diseases and to evaluate the risk factors for steroid-associated osteonecrosis in a prospective MRI study.

METHODS

We prospectively used MRI to study 337 eligible underlying disease patients requiring CS therapy and succeeded in examining 1199 joints (hips and knees) in 302 patients with MRI for at least 1 year starting immediately after the onset of CS therapy (1-year follow-up rate of 90%). The underlying diseases included SLE in 687 joints (173 patients) and a variety of other rheumatological disorders in 512 joints (129 patients).

RESULTS

The incidence of osteonecrosis was significantly higher in SLE patients than in non-SLE patients (37 vs 21%, P = 0.001). Logistic regression analysis revealed that adolescent and adult patients had a significantly higher risk of osteonecrosis compared with paediatric patients [odds ratio (OR) = 13.2], that high daily CS dosage (>40 mg/day) entailed a significantly higher risk of osteonecrosis compared with the dosage of <40 mg/day (OR = 4.2), that SLE patients had a significantly higher risk of osteonecrosis compared with non-SLE patients (OR = 2.6) and that male patients had a significantly higher risk of osteonecrosis compared with female patients (OR = 1.6).

CONCLUSION

These findings suggest that the incidence of CS-associated osteonecrosis varies among different underlying diseases.

Role of hypercoagulability in steroid-induced femoral head necrosis in rabbits

BACKGROUND

The pathogenesis of femoral head necrosis is still uncertain. Both steroid treatment and hypercoagulopathy are considered risk factors. To investigate possible changes in coagulability and histology during steroid-induced osteonecrosis, we used a combination of the Shwartzman reaction and corticoid injections in rabbits to develop an animal model of femoral head necrosis. We studied blood coagulability and histopathological characteristics of the femoral head and liver.

METHODS

A total of 30 rabbits were divided into three groups. In group A, rabbits were given two injections of lipopolysaccharide (40 microg/kg) at an interval of 24 h and were then immediately given one injection of prednisolone acetate (20 mg/kg). In group B, 10 rabbits were given one injection of prednisolone acetate (20 mg/kg). In group C, 10 rabbits were given no treatment and served as controls. At 1, 3, 7, 14, and 21 days after prednisolone injection, coagulability, blood lipid levels, and blood platelet levels were measured; and the femoral head and liver were removed for histopathological examination.

RESULTS

At 24 h after the prednisolone injection in group A, coagulability and blood lipid levels were increased (P < 0.01), and blood platelet levels were decreased (P < 0.01). These abnormal levels were maintained throughout the entire observation period. Histologically, degeneration and necrosis of hepatocytes and osteocytes were found at day 21 after prednisolone injection in group A. In group B, coagulability and blood lipid levels were significantly increased by day 3 after treatment.

CONCLUSIONS

Abnormal hypercoagulability might potentiate the thrombotic status and induce thrombus formation in the presence of steroid-induced necrosis of the femoral head.

Investigation of occurrence of osteonecrosis of the femoral head after increasing corticosteroids in patients with recurring systemic lupus erythematosus

Osteonecrosis (ON) of the femoral head is known to occur commonly in cases with systemic lupus erythematosus (SLE) that received corticosteroid (CS) treatment. However, there have been no detailed reports about the onset of ON in cases with recurrence of SLE. Using MRI, we followed up 17 patients who experienced recurrence of SLE for at least 1 year at our hospital and in whom the CS dose was increased from a maintenance dose to middle to high dose to see if ON would occur. We then compared the group that developed ON and the group that did not with respect to patient characteristics, blood test results, changes in serum lipid levels, and CS dose. ON occurred in five subjects (29.4%), revealing that osteonecrosis occurs not only when CS are first administered but also in cases which the CS dose is increased for recurrence of SLE. Especially, serum cholesterol levels and its rate of increase soared rapidly soon after increasing the CS dose in the ON group as compared with the non-ON group (P < 0.05). This suggests that increased serum lipid levels might be a contributing factor to onset of ON. Moreover, SLE disease activity index 2000 (SLEDAI-2K) scores when the CS dose was increased were significantly (P < 0.05) higher in the ON group, suggesting that SLE disease activity itself is a risk factor for onset of ON.

Hypofibrinolysis, lipoprotein(a), and plasminogen activator inhibitor

Parameters of hypofibrinolysis and thrombophilia were assessed in 20 consecutive patients with bone marrow edema sydrome of the hip who lacked typical risk factors for osteonecrosis. Twenty healthy subjects, matched for age and gender, served as the control subjects. In patients with bone marrow edema syndrome, elevated levels of lipoprotein(a) and plasminogen activator inhibitor were found in nine (45%) and two patients (10%), respectively. Elevation of lipoprotein(a) was present in two patients in the control group; however, plasminogen activator inhibitor levels were normal in this group. Mean levels of lipoprotein(a) were 34.8 mg/dL in the patients with bone marrow edema versus 13.8 mg/dL in the control subjects. Mean concentrations of plasminogen activator inhibitor, apolipoproteins, lipid metabolism parameters, and indicators of thrombophilia did not differ in both groups. Pulsed field gel electrophoresis and Southern blots confirmed the presence of pathologic allelotypes in three patients with elevated levels of lipoprotein(a) who had a familial occurrence of bone marrow edema syndrome. These findings also underline a fundamental role of hypofibrinolysis, mediated by elevated levels of lipoprotein(a) or plasminogen activator inhibitor, or both, in the former idiopathically considered etiology of the bone marrow edema syndrome of the hip.