Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Comparative analysis of titanium coating on cobalt-chrome alloy in vitro and in vivo direct metal fabrication vs. plasma spraying

Background

Titanium surface coating on cobalt-chromium (CoCr) alloy has characteristics desirable for an orthopedic implant as follows: strength, osteointegrative capability, and biocompatibility. Creating such a coated surface takes a challenging process and two dissimilar metals are not easily welded. In our study, we utilized additive manufacturing with a 3D printing called direct metal fabrication (DMF) and compared it to the plasma spraying method (TPS), to coat titanium onto CoCr alloy. We hypothesized that this would yield a coated surface quality as acceptable or better than the already established method of plasma spraying. For this, we compared characteristics of titanium-coated surfaces created by direct metal fabrication method (DMF) and titanium plasma spraying (TPS), both in vitro and in vivo, for (1) cell morphology, (2) confocal microscopy images of immunofluorescent assay of RUNX2 and fibronectin, (3) quantification of cell proliferation rate, (4) push-out biomechanical test, and (5) bone histomorphometry.

Method

For in vitro study, human osteoblast cells were seeded onto the coated surfaces. Cellular morphology was observed with a scanning electron microscope. Cellular proliferation was validated with ELISA, immunofluorescent assay. For in vivo study, coated rods were inserted into the distal femur of the rabbit and then harvested. The rods were biomechanically tested with a push-out test and observed for histomorphometry to evaluate the microscopic bone to implant ratio.

Result

For cell morphology observation, lamellipodia and filopodia, a cytoplasmic projection extending into porous structure, formed on both surfaces created by DMF and TPS. The proliferation of the osteoblasts, the DMF group showed a better result at different optic density levels (p = 0.035, 0.005, 0.001). Expression and distribution of fibronectin and Runx-2 genes showed similar degrees of expressions. The biomechanical push-out test yielded a similar result (p = 0.714). Histomorphometry analysis also showed a similar result (p = 0.657).

Conclusion

In conclusion, DMF is a method which can reliably create a proper titanium surface on CoCr alloy. The resulting product of the surface shows a similar quality to that of the plasma spraying method, both in vivo and in vitro, in terms of biological and mechanical property.

Titanium Powder Coating Using Metal 3D Printing: A Novel Coating Technology for Cobalt-Chromium Alloy Implants

Background

Three-dimensional (3D) printing with a direct metal fabrication (DMF) technology has been innovatively introduced in the field of surface treatment of prostheses. The purpose of this study was to determine whether such modifications on the surface of cobalt-chromium (CoCr) alloy by titanium powder coating using DMF improves the osseointegration ability of CoCr alloy.

Methods

We compared the in vitro and in vivo ability of cells to adhere to DMF-coated CoCr alloy with machining. Biological and morphological responses to human osteoblast cell lines were examined by measuring cell proliferation rate and observing expression of actin filament. For in vivo study, we inserted different specimens in each medulla of the distal femurs of rabbit. After 3 months, the distal femurs were harvested, and a push-out test and histomorphometric analyses were performed.

Results

The cell proliferation rate and cell adhesion in the DMF group were higher compared with those in the machined group. Human osteoblast cells on the DMF-coated surface were more strongly adhered and well-proliferated compared with those on the other surface. In the in vivo test, there was a significant difference in the ultimate shear strength between the DMF and machined groups (2.49 MPa vs. 0.87 MPa, respectively, p = 0.001). In the histomorphometric analysis, there was a significant difference in the mean bone-to-implant contact percentages between the DMF and machined groups (72.3 ± 6.2% vs. 47.6 ± 6.9%, respectively, p < 0.001).

Conclusion

Titanium coating of CoCr alloy with 3D metal printing provides optimal surface characteristics and a good biological surface both in vitro and in vivo.

The biological response to laser-aided direct metal-coated Titanium alloy (Ti6Al4V)

Objectives

Laser-engineered net shaping (LENS) of coated surfaces can overcome the limitations of conventional coating technologies. We compared the in vitro biological response with a titanium plasma spray (TPS)-coated titanium alloy (Ti6Al4V) surface with that of a Ti6Al4V surface coated with titanium using direct metal fabrication (DMF) with 3D printing technologies.

Methods

The in vitro ability of human osteoblasts to adhere to TPS-coated Ti6Al4V was compared with DMF-coating. Scanning electron microscopy (SEM) was used to assess the structure and morphology of the surfaces. Biological and morphological responses to human osteoblast cell lines were then examined by measuring cell proliferation, alkaline phosphatase activity, actin filaments, and RUNX2 gene expression.

Results

Morphological assessment of the cells after six hours of incubation using SEM showed that the TPS- and DMF-coated surfaces were largely covered with lamellipodia from the osteoblasts. Cell adhesion appeared similar in both groups. The differences in the rates of cell proliferation and alkaline phosphatase activities were not statistically significant.

Conclusions

The DMF coating applied using metal 3D printing is similar to the TPS coating, which is the most common coating process used for bone ingrowth. The DMF method provided an acceptable surface structure and a viable biological surface. Moreover, this method is automatable and less complex than plasma spraying.

Cite this article: T. Shin, D. Lim, Y. S. Kim, S. C. Kim, W. L. Jo, Y. W. Lim. The biological response to laser-aided direct metal-coated Titanium alloy (Ti6Al4V). Bone Joint Res 2018;7:357–361. DOI: 10.1302/2046-3758.75.BJR-2017-0222.R1.

Decreased Lumbar Lordosis and Deficient Acetabular Coverage Are Risk Factors for Subchondral Insufficiency Fracture

Subchondral insufficiency fracture (SIF) of the femoral head occurs in the elderly and recipients of organ transplantation. Osteoporosis and deficient lateral coverage of the acetabulum are known risk factors for SIF. There has been no study about relation between spinopelvic alignment and anterior acetabular coverage with SIF. We therefore asked whether a decrease of lumbar lordosis and a deficiency in the anterior acetabular coverage are risk factors. We investigated 37 patients with SIF. There were 33 women and 4 men, and their mean age was 71.5 years (59-85 years). These 37 patients were matched with 37 controls for gender, age, height, weight, body mass index and bone mineral density. We compared the lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope, acetabular index, acetabular roof angle, acetabular head index, anterior center-edge angle and lateral center-edge angle. Lumbar lordosis, pelvic tilt, sacral slope, lateral center edge angle, anterior center edge angle, acetabular index and acetabular head index were significantly different between SIF group and control group. Lumbar lordosis (OR = 1.11), lateral center edge angle (OR = 1.30) and anterior center edge angle (OR = 1.27) had significant associations in multivariate analysis. Decreased lumbar lordosis and deficient anterior coverage of the acetabulum are risk factors for SIF as well as decreased lateral coverage of the acetabulum.