Osteonecrosis of the Knee: The Unintended Consequence of Steroid Abuse

The anti-inflammatory and immunosuppressive properties of steroids allow their use in a wide variety of rheumatological diseases, asthma, inflammatory bowel disease, cancer therapy, and severe viral infections. Though life-saving or organ-saving, long-term clinical use leads to a vast array of complications. Osteoporosis is the most common orthopedic side effect of steroid abuse, while osteonecrosis is a rare occurrence. The risk of osteonecrosis appears to be dose and duration dependent, but several patient factors also play a major role and usually affect the femoral head followed by the knee joint. The long-term effects of steroids must be explained to all patients on therapy, but this risk is missed in individuals who abuse steroids for recreational or performance-enhancing purposes. We describe a male, aged 29 years, who presented with dull aching bilateral knee pain of 2-years' duration after a long-term steroid abuse for weight and muscle mass gain. Radiological and magnetic resonance imaging studies confirmed osteonecrosis of femoral and tibial condyles and secondary degenerative arthritis of the knee joint. Prompt suspicion, early diagnosis, and intervention in osteonecrosis of knee joints, and termination of steroids may reverse the pathology and prevent progression of disease.

Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects

OBJECTIVE

This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis.

DESIGN

An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject.

RESULTS

MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered.

CONCLUSIONS

Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.

Who is the convict; COVID-19 or corticosteroid? Late onset avascular necrosis of hips after COVID-19. A case report with literature review

AIM

Avascular necrosis (AVN) or osteonecrosis is characterized by death of bone tissue due to endothelial damage and vascular abnormality. Coronavirus can induce endothelial damage and abnormal blood clotting, so that COVID-19 is known as a vascular disease. We aim to evaluate the relationship between AVN and COVID-19.

CASE

Here we present a 39-year old man with severe COVID-19 and corticosteroid consumption who developed late onset AVN of both hips 20 month after COVID-19.

CONCLUSION

An awareness of the possible osteonecrosis for all physicians dealing with patients with musculoskeletal problems following COVID-19 is necessary.

Idiopathic lingual mandibular sequestration and its relationship to medication-related osteonecrosis of the jaws (MRONJ): mini review

OBJECTIVE

Idiopathic lingual mandibular sequestration is an uncommon condition that affects the lingual aspect of the mandible and may result in a necrosis of the jaw that is clinically indistinguishable from medication-related osteonecrosis of the jaw. This condition, however, is not associated with the intake of antiresorptive medication and may not require the same safeguards for extended periods of time. The etiology of idiopathic lingual mandibular sequestration is still unknown although trauma has been shown to play an important role.

METHOD AND MATERIALS

PubMed and the Cochrane Library were used to retrieve papers written in English through the years 1970 to 2021 using the key words "idiopathic osteonecrosis," "lingual sequestration," and "idiopathic jaw sequestration." In addition, clinical presentation of the lesion was included.

RESULTS

Idiopathic lingual mandibular sequestration is a benign, mostly self-limiting condition distinct from medication- related osteonecrosis of the jaw.

CONCLUSION

The dental clinician should be familiar with this condition and include it in their differential diagnosis when exposed bone is present with no history of radiation to the area or intake of antiresorptive medication. The course of the condition is usually very mild and may be self-limiting and usually does not require surgical intervention.

[Juvenile osteochondrosis and osteonecrosis]

BACKGROUND

Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis.

RISK FACTORS

Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis.

DIAGNOSTICS

Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed.

THERAPY

The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.

Possible association of methotrexate use with osteonecrosis of the jaw: Systematic review

The aim was to search systematically, evaluate, and then summarize scientific literature about possible methotrexate-associated osteonecrosis of the jaw (ONJ), its signs and symptoms, diagnosis, treatment, and prognosis in adults. After registration at PROSPERO this systematic review was conducted and reported according to the PRISMA checklist. The following databases were systematically searched: MEDLINE, EBSCO, The Cochrane Central Register of Controlled Trials (Central), SCIndex, Scopus, Google Scholar and Registry of clinical studies with human participants. In total 9 studies with 14 patients were included in the review. All cases of ONJ associated with methotrexate were described in patients suffering from Rheumatoid arthritis (RA), and only about 40% of them were taking other concomitant medication described to be associated with ONJ (bisphosphonates). Both sexes were equally affected, and the patients were rather old (over 60 years if age), already taking methotrexate for more than 12 years on average. Antibiotics were ineffective in the treatment of ONJ; after stopping methotrexate, all lesions healed after several months on average; however, half of the cases required covering of the exposed bone with mucosal flap. Recurrence of the methotrexate-associated ONJ was not observed for at least two years after the lesions were healed. Methotrexate-associated ONJ is serious clinical condition that may occur in patients with RA, but given the small number of cases we have found in the literature, direct involvement of methotrexate in the development of ONJ remains elusive.

Epidemiology and risk factors associated with avascular necrosis in patients with autoimmune diseases: a nationwide study

BACKGROUND/AIMS

Avascular necrosis (AVN) is a clinical condition characterized by the death of bone components due to interruption in the blood supply. This study aimed to investigate the epidemiology and determine the risk factors for AVN in patients with autoimmune diseases.

METHODS

We conducted a population-based retrospective cohort analysis using claims data from the Taiwan National Health Insurance Research Database. A total of 49,636 patients with autoimmune diseases between January 1, 2005 and December 31, 2013 were included. Cox regression analysis was used to identify associated risk factors for the development of AVN.

RESULTS

A total of 490/49,636 patients (1.0%) developed symptomatic AVN. The systemic lupus erythematosus patients had a higher risk of AVN compared to other autoimmune diseases. AVN was positively correlated with male sex (p < 0.001), alcoholism (p < 0.001), mean daily prednisolone dosage 7.51 to 30 mg (p < 0.001) and > 30 mg (p < 0.001), and total cumulative prednisolone dose 0 g to 5 g (p = 0.002). However, AVN was inversely correlated with cumulative duration of hydroxychloroquine exposure > 0.6 years (p < 0.001).

CONCLUSION

Male sex, systemic lupus erythematosus, alcoholism, mean daily corticosteroid > 7.5 mg and a total cumulative dose of corticosteroid 0 to 5 g were independently associated with the development of AVN in autoimmune patients. While hydroxychloroquine use > 0.6 years conferred significant protection against the development of AVN. Clinicians should regularly assess patients with risk factors to enable the early diagnosis of AVN.

Prevalence of and Associations With Avascular Necrosis After Pediatric Sepsis: A Single-Center Retrospective Study

OBJECTIVES

Avascular necrosis (AVN) is a rare, but serious, complication after sepsis in adults. We sought to determine if sepsis is associated with postillness diagnosis of AVN, as well as potential-associated risk factors for AVN in children with sepsis.

DESIGN

Retrospective observational study.

SETTING

Single academic children's hospital.

PATIENTS

Patients less than 18 years treated for sepsis or suspected bacterial infection from 2011 to 2017. Patients who developed AVN within 3 years after sepsis were compared with patients who developed AVN after suspected bacterial infection and with patients with sepsis who did not develop AVN.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

AVN was determined using International Classification of Diseases, 9th Edition/10th Edition codes and confirmed by chart review. The prevalence of AVN after sepsis was 0.73% (21/2,883) and after suspected bacterial infection was 0.43% (53/12,276; risk difference, 0.30; 95% CI, 0.0-0.63; p = 0.05). Compared with 43 sepsis controls without AVN, AVN in the 21 sepsis cases was associated with being older, having sickle cell disease and malignancy, higher body mass index, unknown source of infection, and low platelet count in the first 7 days of sepsis. Half of sepsis patients were treated with corticosteroids, and higher median cumulative dose of steroids was associated with AVN (23.2 vs 5.4 mg/kg; p < 0.01). Older age at infection (odds ratio [OR], 1.3; 95% CI, 1.1-1.4), malignancy (OR, 8.8; 95% CI, 2.6-32.9), unknown site of infection (OR, 12.7; 95% CI, 3.3-48.6), and minimal platelet count less than 100,000/µL in first 7 days of sepsis (OR, 5.0; 95% CI, 1.6-15.4) were identified as potential risk factors for AVN after sepsis following adjustment for multiple comparisons.

CONCLUSIONS

Although rare, sepsis was associated with a higher risk of subsequent AVN than suspected bacterial infection in children. Older age, malignancy, unknown site of infection, and minimum platelet count were potential risk factors for AVN after sepsis.

Conservative management of avascular necrosis of the metacarpal head: A case report and brief review

RATIONALE

Avascular necrosis (AVN) of the metacarpal head is rare, and there is no clear consensus on treatment. The main aim of this study was to discuss the possible pathologic-mechanics of its development, epidemiology, radiographic features, and outcome after conservative treatment.

PATIENT CONCERNS

A 14-year-old male with a history of fractures in little finger complained of right-hand pain with a limited range of motion for 1 month. Diagnosis: Imaging examination confirmed the diagnosis of AVN in the long metacarpal finger and ring finger.

INTERVENTIONS

The patient was treated using non-surgical management, such as splint immobilization, non-steroidal anti-inflammatory drugs, and physiotherapy.

OUTCOMES

At the last follow-up 26 months later, the patient was in complete remission with no residual symptoms. Magnetic resonance imaging (MRI) confirmed excellent remodeling and regeneration in the metacarpal head.

LESSONS

Metacarpal head necrosis typically occurs in adolescent patients with a history of trauma. Conservative treatment may sometimes have an excellent prognosis.

Type of bone graft and primary diagnosis were associated with nosocomial surgical site infection after high tibial osteotomy: analysis of a national database

PURPOSE

Although several small-scale studies have reported risk factors for surgical site infection (SSI) after high tibial osteotomy (HTO), no study has collectively analysed risk factors in a large cohort. The present study aimed to clarify the risk factors for SSI after HTO using a national database.

METHODS

Data of inpatients who underwent HTO from 2010 to 2017 were obtained from the Diagnosis Procedure Combination database in Japan. Outcome measures were the incidence of SSI and deep SSI after HTO. Associations between SSI and patient data were examined with multivariable logistic regression analysis.

RESULTS

Among 12,853 patients who underwent HTO, 195 developed SSI (1.52%) and 50 developed deep SSI (0.39%). Univariate analysis showed that male sex, smoking, and longer anaesthesia duration were associated with higher incidences of SSI, whereas a primary diagnosis of osteonecrosis and use of natural bone grafts were associated with lower incidences. In multivariable analysis, SSI was positively associated with male sex, anaesthesia duration longer than 210 min (vs. 150-210 min), and use of artificial bone graft (vs. natural bone graft). SSI was negatively associated with age ≤ 49 years (vs. 50-59 years) and a primary diagnosis of osteonecrosis (vs. osteoarthritis).

CONCLUSION

The present study revealed novel risk factors for SSI after HTO that previous studies have failed to find, including use of artificial bone graft and longer anaesthesia duration; primary diagnosis of osteonecrosis and younger age were novel protective factors. These findings will help surgeons assess risks of SSI after HTO in individual patients.

LEVEL OF EVIDENCE

III.

Open reduction and Salter innominate osteotomy combined with femoral osteotomy in the treatment of developmental dysplasia of the hip: Comparison of results before and after the age of 4 years

OBJECTIVE

This study aimed to compare the clinical and radiological findings of radical reduction (open reduction and Salter innominate osteotomy combined with femoral osteotomy) for children of walking age, younger and older than 4 years in the treatment of with developmental dysplasia of the hip (DDH).

METHODS

In this retrospective study, children of walking age with DDH who underwent radical reduction between 2008 and 2014 were identified. They were then divided into 2 groups according to the age at which the surgery was performed: before and after the age of 4 years. Improvement in the acetabular index was examined on follow-up radiographs. The presence of avascular necrosis (AVN) was determined and classified on the basis of the Kalamchi-MacEwen classification on final follow-up radiographs. Clinical assessment was performed with the modified McKay criteria at the final follow-up appointment.

RESULTS

A total of 19 children (14 girls, 5 boys; mean age=37.5±21 months) (25 hips) were included. Their mean age was 27.9±4.9 and 63.3±19.7 months in children operated before and after the age of 4 years, respectively. The mean follow-up time was 29.9±19 and 19.6±5 months in children operated before and after the age of 4 years, respectively. No significant difference was observed in improvements in the acetabular index between children younger than 4 years (24±6.9°) and those older than 4 years (20.7±6.7°) (p=0.25). According to the modified McKay criteria, all the children younger than 4 years exhibited excellent or good clinical results compared with those operated after the age of 4 years (67%) (p=0.013). At the final follow-up, 64% of all patients demonstrated no radiographical sign of AVN. The rates of AVN were significantly higher in children operated after the age of 4 years (33%) than in those operated before the age of 4 years (19%) (p=0.049).

CONCLUSION

Better clinical and radiographical results can be expected from radical reduction in children undergoing surgery before the age of 4 years.

LEVEL OF EVIDENCE

level III, Therapeutic Study.

Decrease in dysbaric osteonecrosis severity as a result of 45-minute oxygen pre-breathe

Sudden decompression can result in bubble formation as the result of nitrogen gas (N2) dissolved in tissue during disabled submarine escape (DISSUB). This may cause dysbaric osteonecrosis (DON), a condition in long bones where bubbles in fatty marrow result in ischemia and necrosis. Previous research has shown that oxygen (O2) pre-breathe of two hours resulted in a reduction of DON; however, effects of shorter O2 pre-breathe remain uncertain. This study's aim was to understand the effect of shorter lengths of O2 pre-breathe. Eight adult Suffolk ewes (89.5± 11.5 kg) were exposed to 33 feet of seawater (fsw) for 24 hours. They were placed randomly into four groups and exposed to either 45, 30 or 15 minutes of O2 (91-88%) pre-breathe; the controls received none. They were then rapidly decompressed. Alizarin complexone was later injected intravenously to visualize the extent of DON in the right and left long bones (radii, tibiae, femur and humeri). The 30- and 15-minute pre-breathe groups saw the greatest deposition. There was significant decrease of variance in the 45-minute group when compared with all other treatments, suggesting that 45 minutes of O2 pre-breathe is required to effectively increase confidence in the reduction of DON. Similar confidence was not reflected in the 30-minute and 15-minute groups: 45 minutes of pre-breathe was the minimum amount needed to effectively prevent against DON in DISSUB escape at 33 fsw. However, future research is needed to determine how to calculate effective dosages of O2 pre-breathe to prevent DON in any given scenario.

Assessment of jaw osteonecrosis diagnostic criteria in cancer patients with a history of radiation therapy and exposure to bone-modifying agents

BACKGROUND

Osteoradionecrosis (ORN) of the jaw is currently defined by the development of osteonecrosis in head/neck irradiated patients, regardless of lesion exposure. To diagnose medication-related osteonecrosis of the jaw (MRONJ), a history of any radiation therapy to the jaw region must be ruled out. The aim of this study was to assess the accuracy of current osteonecrosis criteria, while introducing new modifications for improved diagnosis and treatment.

METHODS

One hundred and forty-one necrotic lesions were analyzed from patients exposed to bone-modifying agents (BMAs) and/or received head and neck regional radiation therapy, where the maximal dose of radiation exposure to the jaw osteonecrosis site was calculated. Modified diagnostic criteria were used to reassess all cases and a comparison of outcomes was performed using Pearson's Chi-Square/Fisher's exact test.

RESULTS

Only in patients with primary head and neck carcinomas did the maximal mean radiation dose in the necrotic jaw site reach ranges associated with ORN formation (>40 Gy), with individual cases showing exposures as low as 0-2 Gy. Based on the modified diagnostic criteria almost 2/3 of the necrotic cases diagnosed as ORN should be diagnosed as MRONJ.

CONCLUSIONS

ORN diagnosis should only be considered in cases of radiation exposure >40 Gy to prevent misdiagnosis and suboptimal treatment. A modified criterion for MRONJ diagnosis is recommended where radiation exposure <40 Gy in the necrotic site is included. In cases with exposure >40 Gy and BMA administration, an additional modification to diagnostic criteria of 'medication- and radiation-related osteonecrosis of the jaw', should be used.

Musculoskeletal Effects of Cancer and Cancer Treatment

Improvements in cancer treatment have led to prolonged survival and increased rates of cure. An estimated 14 million cancer survivors live in the United States. The cornerstones of cancer treatment, including radiation, chemotherapy, and surgery, give rise to a host of chronic health conditions, some of which affect the musculoskeletal system. As survivorship continues to improve, orthopaedic surgeons across all subspecialties will be tasked with managing these complications of treatment. This article reviews orthopaedic health concerns secondary to cancer treatment that are likely to present to orthopaedic surgeons for evaluation, such as osteoporosis, osteonecrosis, secondary malignancies, radiation-associated fractures, exercise tolerance, and perioperative evaluation.

Salivary Biomarkers and Their Application in the Diagnosis and Monitoring of the Most Common Oral Pathologies

Saliva is a highly versatile biological fluid that is easy to gather in a non-invasive manner—and the results of its analysis complement clinical and histopathological findings in the diagnosis of multiple diseases. The objective of this review was to offer an update on the contribution of salivary biomarkers to the diagnosis and prognosis of diseases of the oral cavity, including oral lichen planus, periodontitis, Sjögren’s syndrome, oral leukoplakia, peri-implantitis, and medication-related osteonecrosis of the jaw. Salivary biomarkers such as interleukins, growth factors, enzymes, and other biomolecules have proven useful in the diagnosis and follow-up of these diseases, facilitating the early evaluation of malignization risk and the monitoring of disease progression and response to treatment. However, further studies are required to identify new biomarkers and verify their reported role in the diagnosis and/or prognosis of oral diseases.

Osteonecrosis of the Lunate: Kienböck Disease

Kienböck disease, osteonecrosis of the lunate, is a well-known but poorly understood complication seen by hand surgeons. This review presents the background and important patient-specific parameters of the disease and reviews the numerous treatment options that exist for the disease.

Osteonecrosis in sickle cell disease: an update on risk factors, diagnosis, and management

Osteonecrosis, a form of ischemic bone injury that leads to degenerative joint disease, affects ∼30% of people with sickle cell disease. Although osteonecrosis most commonly affects the femoral head (often bilaterally, with asymmetric clinical and radiographic progression), many people with sickle cell disease also present with multifocal joint involvement. We present the case of a young woman with bilateral osteonecrosis of the femoral head at varying stages of progression; we also highlight other important comorbid complications (eg, chronic pain requiring long-term opioids, debility, and social isolation) and postoperative outcomes. In this review, partly based on recommendations on osteonecrosis management from the 2014 evidence-based report on sickle cell disease from the National Heart, Lung and Blood Institutes, we also discuss early signs or symptoms of osteonecrosis of the femoral head, radiographic diagnosis and staging criteria, hydroxyurea effect on progression to femoral head collapse, and surgical outcomes of total hip arthroplasty in the modern era. In summary, we failed to find an association between hydroxyurea use and femoral head osteonecrosis; we also showed that evidence-based perioperative sickle cell disease management resulted in superior postoperative outcomes after cementless total hip arthroplasty in sickle cell-related osteonecrosis of the femoral head.

Conservative tibiotalocalcaneal fusion for partial talar avascular necrosis in conjunction with ankle and subtalar joint osteoarthritis in Kashin-Beck disease: A case report

RATIONALE

Kashin-Beck disease (KBD) is known for some typical characters like finger joint enlargement, shortened fingers, and dwarfism. However, Avascular necrosis (AVN) of the talus in KBD has rarely been reported in the literature. Here, we reported on a KBD patient presented with partial AVN of the talus in conjunction with ankle and subtalar arthritis.

PATIENT CONCERNS

A 50-year-old woman presented with severe pain and limited range of motion in her left ankle and subtalar joint while walking for 2 years. She had been walking with the aid of crutches for many years. Conservative treatment with rigid orthosis and activity restriction could not help reduce the pain in the left foot.

DIAGNOSES

Radiographs demonstrated that partial AVN was developed in the body of the talus and arthritis was viewed in the left ankle and subtalar joint. Hence, we established the diagnosis of partial talar AVN in conjunction with ankle and subtalar arthritis.

INTERVENTIONS

A conservative tibiotalocalcaneal fusion attempting to preserve as much viable talar body as possible was performed using a humeral locking plate and 2 cannulated compression screws.

OUTCOMES

Bone union proved by CT scan and a good alignment of the left limb were achieved at 4-month follow-up postoperatively.

LESSONS

Partial AVN of the talus along with ankle and subtalar arthritis in KBD patients has rarely been reported as it is not a common characteristic of KBD in clinical practice. Conservative tibiotalocalcaneal fusion could help preserving much more viable talar body, maintaining most structural integrity of the ankle joint, and achieving a stable and plantigrade foot postoperatively.

[Maxillary osteonecrosis after denosumab treatment]

A 58-year-old patient with a history of intravenous use of denosumab was referred to the department of oral and maxillofacial surgery with inadequate recovery after a series of extractions. During physical and radiological examination, several sites of exposed necrotic bone with purulent discharge were seen, and the maxilla appeared fractured at the level of Le Fort 1. Treatment consisted of intravenous administration of antibiotics with consecutive sequestrectomy of the maxilla under general anaesthesia. While Medication Related Osteonecrosis of the Jaw (MRONJ) is most commonly seen in patients treated with bisphosphonates, in the past decade, it has become apparent that other types of medication, most notably denosumab, can cause comparable disorders. Treatment of MRONJ strongly depends on the stage the disease is in. In patients with a history of denosumab or bisphosphonate use (administered either intravenously or orally in combination with corticosteroids), abnormal radiological findings, or developing osteonecrosis, referral to a department of oral and maxillofacial surgery is recommended.

Stage III Kienböck's disease treated with hyperbaric oxygen: the role of an unusual approach to a rare condition

Kienböck's disease is a rare condition characterised by avascular necrosis of the lunate bone. Its natural history and aetiopathogenesis have not yet been clarified, nor are its triggering factors identified. We present a case of a 17-year-old male gymnast, without relevant medical/family history, with stage IIIA Kienböck's disease diagnosed in 2016. Initially, submitted to conservative treatment that proved to be insufficient. Consequently, surgical treatment was proposed, but refused. The patient instead underwent experimental treatment with hyperbaric oxygen (120 sessions, 100% oxygen at 2.5 atm, for 70 min periods, once daily, five times per week). In April 2018, a favourable clinical and radiological evolution was observed, with an improvement in the patterns of pain, motion and strength and an almost complete involution of the process of aseptic necrosis of the semilunar. To the best of our knowledge, this is the first report of Kienböck's disease treated with hyperbaric oxygen.

Characteristics, management, and outcomes of spontaneous osteonecrosis of the knee in Indian population

PURPOSE

Spontaneous osteonecrosis of the knee affects the medial femoral condyle in patients above 55 years of age. Many reports and studies are available from western countries. But there is a gross paucity of literature on spontaneous osteonecrosis of the knee (SPONK) in the Indian subcontinent, either it is under-reported or detected at a later stage. The aim of our study was to detect SPONK in Indian population and describe its characteristics, treatment, and outcome.

MATERIAL AND METHOD

A prospective study was conducted over a period of three years. All patients above 18 years with knee pain at rest and medial condyle tenderness without joint laxity were evaluated with plain radiographs and MRI. Further tests were done if radiological signs of osteonecrosis were present. Various parameters were recoded like Visual Analog Scale (VAS), Knee Society Score (KSS), and MRI Osteoarthritis Knee Score. Conservative treatment consisted of a combination of NSAIDs and bisphosphonates. Decompression with bone grafting was done if there was no improvement or deterioration at three month follow-up.

RESULTS

Ten patients were diagnosed with SPONK. The mean age was 50 years with male predominance (60%) with the involvement of medial femoral condyle (80%) or left knee (70%). Most cases were in Koshino stage 1. Mean VAS was 6.5 and mean KSS was 59. All clinical parameters showed improvement at one year.

DISCUSSION

A study with a bigger sample size and longer follow-up is needed to fill the lacunae of literature on this topic from the Indian subcontinent. In spite of the limitations, we did observe that in our population, males were more commonly affected than females, which is contrary to most studies on the subject. Also, the disease had an early age of onset (50 years) in Indian population as compared to Western and East Asian populations.

CONCLUSION

Combined therapy of NSAIDs and bisphosphonates shows excellent results over a period of one year. Joint-preserving surgeries are effective even in Koshino stage 3 SPONK.

Differences between osteoradionecrosis and medication-related osteonecrosis of the jaw

PURPOSE

The appearance of osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ) is similar, but clinically important differences between ORN and MRONJ exist. The aim of this study was to compare the clinical data between ORN and MRONJ and to reveal the critical differences between these diseases.

METHODS

We retrospectively reviewed the epidemiological data, clinical findings, and treatment in 27 ORN and 61 MRONJ patients. Radiographic signs before the initiation of treatment were also assessed.

RESULTS

The median age (P = 0.0474) and the ratio of female to male patients (P < 0.0001) were significantly higher in MRONJ patients. There were significantly more MRONJ patients who reported a history of pain when compared with ORN patients (P = 0.0263). As an aetiological factor, tooth extraction was significantly more relevant to MRONJ than ORN (P = 0.0352). When assessing the radiographic signs on computed tomographic images, periosteal reaction was found only in MRONJ patients (P = 0.0158). Minimal debridement was performed significantly more frequently for MRONJ (P = 0.0093), and by contrast, surgical resection was performed more frequently for ORN (P = 0.0002).

CONCLUSIONS

Understanding the clinical and underlying pathological differences between ORN and MRONJ probably contributes to the selection of appropriate treatment for each patient.

Radiological and clinical outcomes of medial approach open reduction by using two intervals in developmental dysplasia of the hip

OBJECTIVE

To evaluate the midterm clinical and radiological outcomes of the medial approach using two intervals for developmental hip dysplasia (DDH).

METHODS

The study involved 62 hips of 47 patients (41 girls, 6 boys) treated with medial approach for DDH from 1999 to 2010. The age of the patients at surgery was 18.7 ± 2.25 months. Follow up of the patients was 11.3 ± 3.07 years. The age of the patients at the last follow up was 12.6 ± 1.74 years. According to the Tönnis classification, 13 hips were grade II, 27 hips were grade III and 22 hips were grade IV. Patients were evaluated according to Omeroglu radiological criteria and modified McKay functional criteria. The presence of avascular necrosis (AVN) of the hip was questioned using the KalamchiMacEwen classification.

RESULTS

Radiologically, forty eight (77%) hips were evaluated as "excellent", 8 (13%) hips as "good" and 5 (8%) hips as "fair plus" and 1 (%2) hip as "fair minus". Two (3%) patients had type 1 temporary AVN and one (1%) patient had type 4 AVN with coxa magna and overgrowth of the greater trochanter. According to McKay functional criteria, 56 (90%) hips had "excellent" and 6 (10%) had "good" results. Two (3.2%) hips of one patient had to be reoperated with Salter osteotomy and femoral shortening + derotation osteotomy.

CONCLUSION

Medial approach using two separate intervals for tenotomy and capsulotomy does not jeopardize the medial circumflex or the femoral vessels and yields satisfactory midterm results for children 18 months old with dysplasia of the hip.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Multiple Vertebral Osteonecroses (Kümmell's Disease) After 10 Years on Denosumab: Is Osteocyte Apoptosis to Blame?

We report here a case of multiple vertebral osteonecroses with intrasomatic gaseous dissection (Kümmell's disease) occurring 1 year after the end of a 10-year course of denosumab treatment for osteoporosis without fractures. Histomorphometry and bone remodeling markers revealed major bone resorption and the persistence of an inhibition of bone formation. The presence of multiple empty lacunae in the bone provided evidence for high levels of osteocyte apoptosis. Osteocytes direct bone resorption (via the RANK/RANK-L/osteoprotegerin system) and formation (Wnt system, with SOST and DKK1) pathways. The vertebral osteonecrosis in our case may, therefore, have resulted from osteocyte apoptosis, decompensated by the sudden reactivation of bone remodeling after the cessation of denosumab treatment.

Oral Methotrexate-related Lymphoproliferative Disease Presenting with Severe Osteonecrosis of the Jaw: A Case Report and Literature Review

Long-term methotrexate (MTX) treatment can cause MTX-related lymphoproliferative disorder (MTX-LPD). We experienced a case of MTX-LPD that was associated with severe osteonecrosis of the jaw mimicking medication-related osteonecrosis of the jaw. The patient was an 81-year-old woman with rheumatoid arthritis (RA) who was treated with MTX and bisphosphonate. After 7 years, she was referred to our department for the assessment of giant ulcer and exposure of the alveolar bone of the left maxilla. Histopathological and immunological analyses confirmed a diagnosis of MTX-LPD. At seven months after the cessation of MTX treatment, the ulcerative and necrotic lesions had markedly decreased in size. A 1-year follow-up examination showed no evidence of recurrence and good RA control.

Diagnostics of femoral head status in humans using laser spectroscopy - In vitro studies

Osteonecrosis of the femoral head (ONFH), a recalcitrant and disabling disease, is caused by inadequate or fully disrupted blood supply to the affected segment of the subchondral bone. Theoretically, there will develop gas-filled pores during the bone decay process due to lacking blood supply. Unfortunately, the relationship between the gas-filled pores and ONFH is still unclear. Here, we have introduced diode laser absorption spectroscopy to detect oxygen and water vapor signals in the femoral heads from hip replacement in 19 patients. Five samples are affected by osteoarthritis (OA) and the others are related to ONFH. Oxygen and water vapor signals could be obtained, demonstrating the presence of gas-filled pores in both the OA and ONFH groups while the measurement results showed no significant difference. A study of gas exchange was also performed on one excised bone sample to study how these gas pores communicate with the ambient air. The results suggested that the obtained oxygen signals inside the bone samples originate from the invasion of ambient air, which is not expected in vivo. In conclusion, the ability to detect the gas signal of laser absorption spectroscopy shows the potential for the medical application of assessing the human femoral head in vivo.

A Simple Procedure for the Evaluation of Bone Vitality by Staining with a Tetrazolium Salt

Presently, no intra-operative method for a direct assessment of bone vitality exists. Therefore, we set out to test the applicability of tetrazolium-based staining on bone samples. The explanted femoral heads of 37 patients were used to obtain either cancellous bone fragments or bone slices. Samples were stained with 2,3,5-triphenyl-2H-tetrazolium chloride (TTC) or 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (thiazolyl blue, MTT) at different times (one to twelve hours) after explantation. Staining was quantified either spectrophotometrically after extraction of the dyes or by densitometric image analysis. TTC-staining of cancellous bone fragments and bone slices, respectively, indicated the detectability of vital cells in both types of samples in a window of up to six hours after explantation. Staining intensity at later time-points was indistinguishable from the staining of untreated samples or sodium azide treated samples, which represent dead cells. In contrast, MTT-staining of bone slices revealed intense unspecific staining, which obscured the evaluation of the vitality of the samples. The lack of a detectable increase of colour intensity in TTC-stained bone samples, which were treated more than six hours after explantation, corresponds to reduced fracture healing. The described simple procedure could provide a basis for an intraoperative decision by the orthopaedic surgeon.

Bone marrow oedema predicts bone collapse in paediatric and adolescent leukaemia patients with corticosteroid-induced osteonecrosis

OBJECTIVES

Corticosteroid treatment of paediatric leukaemia patients can lead to osteonecrosis (ON). We determined whether bone marrow oedema (BME) is an early sign of progressive ON and eventual bone collapse.

METHODS

In a retrospective study, two radiologists reviewed MR imaging characteristics of 47 early stage epiphyseal ON in 15 paediatric and adolescent leukaemia patients. Associations between BME on initial imaging studies and subchondral fracture, disease progression and bone collapse were assessed by Cochran-Mantel-Haenszel tests. Differences in time to progression and bone collapse between lesions with and without oedema were assessed by log rank tests.

RESULTS

Forty-seven occurrences of ON were located in weight bearing joints, with 77% occurring in the femur. Seventeen lesions progressed to collapse, two lesions worsened without collapse, and 28 remained stable or improved. BME was significantly associated with subchondral fracture (p = 0.0014), disease progression (p = 0.0015), and bone collapse (p < 0.001), with a sensitivity and specificity of 94% and 77%, respectively, for bone collapse. Time to progression for ON with oedema was 2.7 years (95% CI: 1.7-3.4); while the majority of no-oedema ON were stable (p = 0.0011).

CONCLUSIONS

BME is an early sign of progressive ON and eventual bone collapse in paediatric and adolescent leukaemia patients.

KEY POINTS

• Bone marrow oedema in corticosteroid-induced osteonecrosis predicts progression to bone collapse. • Bone marrow oedema is associated with subchondral fractures in corticosteroid-induced osteonecrosis. • Bone marrow oedema can be used to stratify patients to joint-preserving interventions. • Absence of bone marrow oedema can justify a "wait and watch" approach.

Cryptococcal Maxillary Osteomyelitis and Osteonecrosis in a 18-Month-Old Dog

An 18-month-old neutered male labradoodle was treated with surgical debridement for maxillary osteomyelitis and sequestrum formation. Histopathologic findings of the necrotic bone were consistent with Cryptococcus subspecies, confirmed with latex agglutination serum titer testing. The patient responded to a combination of fluconazole and surgical debridement and was titer negative after 8 months of medical therapy. The patient never exhibited signs of systemic illness which is commonly reported with cryptococcosis. Cryptococcus subspecies infection in dogs in the Pacific Northwest is part of an ongoing outbreak in the region, first reported in 2001, and is associated with specific risk factors. This is the first published case of oral cryptococcosis from primary inoculation.

Dental treatments, tooth extractions, and osteonecrosis of the jaw in Japanese patients with rheumatoid arthritis: results from the IORRA cohort study

This study aimed to evaluate dental treatments, tooth extractions, and osteonecrosis of the jaw (ONJ) in Japanese patients with rheumatoid arthritis (RA). Patients with RA enrolled in our cohort completed self-administered questionnaires, which included questions regarding their dental treatments, tooth extractions by dentists during the past 6 months, and past history of ONJ. The history of ONJ was validated with the patients' medical records. Logistic regression was used to determine the association of variables with dental treatments and tooth extractions during the past 6 months. Among 5695 Japanese patients with RA who responded to the questionnaires (mean age, 61.0 years; 85.6 % female), 2323 patients (40.8 %) and 378 patients (6.6 %) reported having had dental treatments and tooth extractions performed by a dentist within the past 6 months, respectively. In multivariate models, advanced age was significantly (P < 0.0001) associated with both dental treatments and tooth extractions during the prior 6-month period, and ever smoking was significantly (P = 0.023) correlated with tooth extractions during that time. Among patients who reported a history of ONJ, we confirmed five cases of ONJ with patient medical records. The prevalence of ONJ was 0.094 % among all RA patients and 0.26 % among female RA patients ≥65 years of age (n = 1888). Our data suggest that more than a few Japanese patients with RA have dental complications that require care by dentists, and that Japanese rheumatologists and dentists should cooperate to improve dental health in patients with RA.

Juvenile Lunatomalacia—Is this Kienböck’s Disease?

An 8-year-old boy with stage III Kienböck’s disease was treated by immobilization of the wrist. He made a complete clinical recovery and serial X-rays and MRI scans demonstrated complete revascularization of the lunate which regained near normal architecture.

Report of a jaw osteonecrosis possibly caused by denosumab

PURPOSE

To report a case of osteonecrosis of the jaw (ONJ) occurring in an implant area possibly related to denosumab, a relatively new antiosteoporotic agent.

MATERIALS AND METHODS

Two months following the extraction of both maxillary first molars, a bilateral maxillary sinus floor elevation was performed on a 64-year-old female patient under a biannual 
60 mg denosumab antiosteoporotic treatment. Seven months later, two implants were inserted in a single-stage procedure in each of the grafted sinuses. After 3 months, the implants underwent prosthetic rehabilitation at one side, and a series of failures that led to an ONJ instalment at the other side.

RESULTS

The ONJ persisted over 7 months and was only resolved by a surgical approach consisting of a piezoelectric osteotomy and platelet-rich fibrin with a tension-free wound closure.

CONCLUSIONS

A cumulative effect of denosumab is likely to be associated with a jaw osteonecrosis, which in this case was manageable using a surgical approach with no need to interrupt the appropriate drug treatment course. Conflict of interest statement: The authors certify that they are not affiliated with, or involved in any organisation or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

Otolaryngology Concerns for Illicit and Prescription Drug Use

Concern for illicit and restricted drug use in otolaryngology is similar to other surgical specialties with a few notable exceptions. Many illicit drugs are consumed transnasally. Repeated nasal exposure to stimulants or narcotics can cause local tissue destruction that can present as chronic rhinosinusitis or nasoseptal perforation. Further, the Food and Drug Administration has taken a stance against codeine for pediatric patients undergoing adenotonsillectomy. They have identified an increased risk of death postoperatively with these medications. Because codeine has been the most commonly prescribed narcotic, this has shifted the standard practice.

The importance of early diagnosis in spontaneous osteonecrosis of the knee - A case series with six year follow-up

BACKGROUND

Spontaneous osteonecrosis of the knee has an unknown aetiology. Management options include conservative, surgical and pharmacological interventions. The aim of this study was to report the experience of the authors in conservative management of SONK using non-operative measures by analysing the functional outcome and need for surgical intervention.

MATERIALS AND METHODS

All patients treated for SONK between 1st August 2001 and 1st April 2014 were retrospectively reviewed. Treatment consisted of touch-down weight bearing for around six weeks. MR imaging was evaluated for size of lesion, the condyles involved and the time taken for resolution. Tegner Activity Scale, VAS pain, Lysholm, WOMAC and IKDC scores were recorded at presentation and final follow-up (mean six years, range six months to 13years).

RESULTS

Forty cases were included; the mean age of the group was 55.3years and 67.5% were male. The medial femoral condyle was the most commonly affected (52.5%). A statistically significant improvement was reported in all functional outcome measures (p<0.001). Only one patient required arthroscopic surgical intervention and no patients required arthroplasty during the follow-up period.

CONCLUSION

Early stage spontaneous osteonecrosis of the knee can be managed successfully without surgery if diagnosed early. Thus early investigation of acute knee pain with MRI scanning is recommended.

Avascular necrosis of the jaws as initial presentation of acute leukemia

Leukemia is a malignant neoplasm of hematologic origin occurring from disorganized proliferation or increased life span of white cells. The initial manifestations of leukemia are generally signs of bone marrow failure, such as pallor, fatigue, fever, bleeding, and infection related to peripheral blood cytopenias. Few reports have described osteonecrosis, especially in the femoral head, as an initial manifestation of acute lymphoblastic leukemia. To the best of our knowledge, osteonecrosis of the jaw has not been reported as a first sign of leukemia. Here, two cases of osteonecrosis of the jaw as an initial manifestation of acute leukemia are reported, as well as a review of the literature regarding the main oral manifestations of leukemia.

Very early development of steroid-associated osteonecrosis of femoral head in systemic lupus erythematosus: prospective study by MRI

The objective of this study was to define prospectively the early development of corticosteroid-induced osteonecrosis of femoral head (ONF) in patients with systemic lupus erythematosus (SLE) and to identify the association of initial steroid treatment with the development of early (silent) ONF. Forty-five patients who were newly diagnosed as having SLE and required 40 mg/day or more prednisolone were enrolled. To detect silent ONF, examinations using magnetic resonance imaging (MRI) were done three months after starting steroid therapy, followed by every year’s MRI and plain radiography for over five years. Clinical and laboratory data were compared between silent ONF and non-ONF groups. Of 45 patients, 15 (33%) developed silent ONF and five (11%) symptomatic ONF. It was of interest that MRI detected silent ONF very early (by three months) in 14 patients (93%). It should be noted that pulse therapy with 1000 mg/day methylprednisolone was found to be done very frequently (13 of 15, 87%) in the silent ONF group compared to non-ONF group (11 of 30, 37%) (P, 0.01) although other clinical features were not significantly different between both groups. High dose corticosteroids caused elevation of serum levels of total cholesterol, albumin, and leukocyte count in most of patients. The degree of elevation of those parameters at one or three months was more prominent in the silent ONF group. In particular, the change ratio of total cholesterol at one month was outstanding in the silent ONF group compared to non-ONF group (0.551 versus 0.374, P, 0.05). In conclusion, pathological ONF develops very early in one-third of SLE patients who received high dose corticosteroids and steroid pulse therapy could be a significant risk factor. An abrupt elevation of serum total cholesterol and/or sensitivity to steroids seem to be associated with the pathogenesis of ONF.

Disease activity as a major risk factor for osteonecrosis in early systemic lupus erythematosus

This study Identifies the possible risk factors for osteonecrosis (ON) in a homogenous group of early system lupus erythematosus (SLE). Forty-six consecutive SLE patients (<5 years duration) followed at the Lupus Clinic, were enrolled between 2004 and 2005. An extensive clinical and laboratory evaluation using a standard electronic protocol established since 1999, including osteonecrosis symptoms and appropriate magnetic resonance imaging (MRI), were carried out at 1—6 months intervals. All other asymptomatic for osteonecrosis patients at study entry underwent MRI. ON confirmed by MRI was found in 10 of 46 patients (22%). Age, disease duration, clinical vascular features, frequency of thrombophilia and hypofibrinolysis factors and the lipoprotein profile were comparable in patients with and without osteonecrosis ( P > 0.05). Remarkably, the frequency of patients with system lupus erythematosus disease activity index (SLEDAI) ≥8 in the previous year of osteonecrosis clinical diagnosis was significantly higher when compared to patients without this manifestation (60.0% versus 19.4%, P = 0.011), supported by the higher glucocorticoid cumulative dose in the same period ( P = 0.045). In contrast, these two parameters evaluated in 13th—24th months preceding osteonecrosis diagnosis were similar in patients with and without osteonecrosis ( P > 0.05). In the logistic regression analysis only SLEDAI remained as an independent risk factor for ON (OR = 6.78, CI = 1.05—43.55, P = 0.04). Disease activity in the previous year of ON clinical diagnosis is the main predictor factor for the development of this complication in early SLE. Lupus (2007) 16, 239—244.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

[Diagnostic analysis of the radiologic characteristics in osteoporotic Kiinmmel's disease]

OBJECTIVE

To explore the diagnostic value of the radiologic characteristics of osteoporotic Kummell's disease.

METHODS

Total 16 patients with pathologically confirmed osteoporotic Kummell's diseases were reviewed from May 2010 to May 2012, including 4 males and 12 females with the mean age of 73.4 years (ranged, 67 to 83 years old). Radiologic imagings of all patients, including X-ray, CT and MRI, were analyzed retrospectively.

RESULTS

Intravertebral linear clefts could be seen on the AP and lateral X-ray films of vertebrae. Sagittal and axial CT scans demonstrated the vacuum cleft phenomenon with liquid and air was identified within the vertebral body. Sagittal MRI showed the callapsed vertebral segment and the area of fluid signal with clear and intact border within the vertebral body. The fluid signal was low on T1-weighted images and high on T2-weighted images and stir images, which was corresponding to an intravertebral vacuum cleft.

CONCLUSION

The radiologic characteristics of Kurmmell's diseases can provide valuable evidences for the early diagnosis.

What Is the Radiographic Prevalence of Incidental Kienböck Disease?

BACKGROUND

Kienböck disease is characterized by osteonecrosis of the lunate. Not all patients with radiographic evidence of the disease experience symptoms bothersome enough to consult a doctor. Little research has been performed on the prevalence of Kienböck disease, and the prevalence in the asymptomatic population is unclear. Knowledge of the natural course of the disease and how often patients are not bothered by the symptoms is important, because it might influence the decision as to whether disease-modifying treatment would be beneficial.

QUESTIONS/PURPOSES

(1) What is the prevalence of incidental and symptomatic Kienböck disease? (2) What are the factors associated with incidental and symptomatic Kienböck disease? (3) Are there differences in Lichtman stage distribution between incidentally discovered and symptomatic Kienböck disease?

METHODS

We retrospectively searched radiology reports of all MRI scans, CT scans, and radiographs that included the wrists of 51,071 patients obtained over an 11-year period at one institution to screen for Kienböck disease and avascular necrosis of the lunate. Corresponding MR images, CT scans, or radiographs were reviewed by an orthopaedic hand surgeon to confirm the presence of Kienböck disease when the report was inconclusive. The medical record was reviewed to determine whether the radiographic Kienböck disease was incidental. Prevalences were calculated for both symptomatic and incidental Kienböck disease. Additionally, we assessed the association of age, sex, and race with incidental and symptomatic Kienböck disease as well as the radiographic severity according to the Lichtman classification and calculated odds ratios.

RESULTS

We identified 51 cases (0.10%) of incidental Kienböck disease and 87 cases (0.17%) of symptomatic Kienböck disease out of 51,071 patients. Patients with incidental Kienböck were older (mean, 54 years; SD, 17; mean difference, -6.1; 95% confidence interval [CI], -11 to -0.96; p = 0.020) and patients with symptomatic Kienböck disease were younger (mean, 43 years; SD, 14; mean difference, 5.1; 95% CI, 1.2-9.0; p = 0.010) compared with the group of patients without Kienböck disease (mean, 48 years; SD, 19). Lunate collapse (Lichtman Stages III and IV) was seen in nine of 51 patients (18%) with incidental Kienböck disease and in 44 of 87 patients (51%) with symptomatic Kienböck disease (odds ratio, 0.21; 95% CI, 0.086-0.51; p < 0.001). Our study did not identify any other factors associated with Kienböck disease.

CONCLUSIONS

We found that Kienböck disease is diagnosed on radiographs in a notable number of asymptomatic patients and that asymptomatic patients are more likely to have precollapse stages of the disease. This suggests that symptoms and disability do not correlate with pathophysiology, progression, or activity. Patients and surgeons benefit from awareness that symptoms are not a good indicator of the severity or prognosis of pathophysiology and that lunate osteonecrosis can exist with no or insufficient symptoms. This is important when considering treatment, because we cannot distinguish active disease at risk of collapse that could merit disease-modifying treatment from disease that will not progress.

LEVEL OF EVIDENCE

Level III, prognostic study.

Analysis of risk factors for poor prognosis in conservatively managed early-stage spontaneous osteonecrosis of the knee

BACKGROUND

Management guidelines for early-stage spontaneous osteonecrosis of the knee (SONK) have not been established. The purposes of this study were to review the outcome of conservative treatment for patients with early-stage SONK and to examine clinical factors affecting the prognosis.

METHODS

Diagnosis of early-stage SONK was made based on the criteria consisting of specific clinical features including magnetic resonance imaging (MRI) findings. During the study period, all patients with this diagnosis underwent standardized conservative treatment. The study population comprised 38 knees in 36 patients with a mean age at presentation of 66.4years. The mean follow-up period was 34.9months. During the treatment course, progressive joint space narrowing or collapse of bony contours identified in serial follow-up radiographs was regarded as indicating a poor prognosis. The significance of potential prognostic factors such as age, gender, obesity, coronal alignment, lesion size, and MRI findings was analyzed using a multivariate logistic regression analysis.

RESULTS

The prognosis was defined to be poor in eight knees (21.1%). The multivariate logistic regression analysis for potential risk factors revealed that only varus alignment with a femorotibial angle (FTA) of 180° or more on the initial radiograph was significantly associated with the poor prognosis (P=0.01, odds ratio 28.1) while no other factors significantly correlated with the prognosis.

CONCLUSIONS

Approximately 80% of patients with early-stage SONK could be managed successfully with conservative treatment without progression of the disease process. The presence of varus deformity (FTA of 180° or more) was significantly associated with poor prognosis complicated with progressive deformity and prolonged disability.

LEVEL OF EVIDENCE

Level IV, case series.