Degree of corticosteroid treatment within the first 2 months of renal transplantation has a strong influence on the incidence of osteonecrosis of the femoral head.
Shibatani Masahiko,Fujioka Mikihiro,Arai Yuji,Takahashi Kenji,Ueshima Keiichiro,Okamoto Masahiko,Yoshimura Norio,Hirota Yoshio,Fukushima Wakaba,Kubo Toshikazu
Acta orthopaedica
BACKGROUND AND PURPOSE:It has been suggested that avascular osteonecrosis (AVN) of the femoral head develops early after renal transplantation. We evaluated the relationship between risk of AVN and dose of steroids administered in different time periods. METHODS:Development of AVN was determined using MRI at 3-6 weeks, 9-12 weeks, 24 weeks, and 12 months after transplantation in 150 patients (96 males). We investigated possible associations between acute rejection reactions, the dose of cyclosporine, tacrolimus use, total steroid dose by the second, fourth, sixth, or eighth weeks after transplantation, and incidence of AVN. RESULTS:There was no statistically significant difference between incidence of AVN and presence or absence of an acute rejection reaction. We found a statistically significant association between AVN incidence and the total dose of steroids administered during the first 2 months after transplantation, and there was a doseresponse relationship. No other statistically significant associations were found. INTERPRETATION:Our findings confirm that the total dose of steroids given within the first 2 months after renal transplantation has a great influence on the incidence of AVN.
10.1080/17453670810016641
Factors associated with osteonecrosis in Thai lupus patients: a case control study.
Uea-areewongsa Parichat,Chaiamnuay Sumapa,Narongroeknawin Pongthorn,Asavatanabodee Paijit
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases
OBJECTIVE:To identify associated factors for the development of osteonecrosis of a femoral head (ON) in patients with systemic lupus erythematosus (SLE). METHODS:We conducted a retrospective nested case-control study from SLE patients who attended the Rheumatology Clinic at Phramongkutklao Hospital from 1992-2008. Cases were defined as SLE patients, who had clinically apparent ON (confirmed by plain radiographs or magnetic resonance imaging). For each case, a control was selected and matched to the case by age and disease duration. The main outcome measure was the odds ratio (OR) of ON among SLE patients. The clinical and laboratory variables thought to be risk factors of ON variables were compared between patients who did and did not develop ON. Significant and clinically relevant variables were then examined by a stepwise logistic regression model. RESULTS:Of 186 SLE patients, we identified 41 patients who developed ON during the course of follow-up. Twenty patients were available for data analysis. From the univariate analysis, incidence of renal involvement and the use of steroids (recorded as evidenced by maximum and mean daily prednisolone dose) were significantly higher in the ON group than in controls. The use of antimalarials was significantly lower in patients with ON than in controls. No difference in disease activity, lipid profiles or anticardiolipin antibody was found between groups. In the logistic regression, the presence of renal involvement remained as a positive associated factor for ON (OR = 7.80, CI = 1.249-48.748, P = 0.028) and the use of antimalarial drugs was a negative associated factor for ON (OR = 0.09, CI = 0.009-0.961, P = 0.046). CONCLUSION:The presence of renal involvement was associated with ON and the antimalarial use may have a protective effect for ON in Thai patients with SLE. The findings from this study further support the use of antimalarial drugs in SLE patients.
10.1097/RHU.0b013e3181ba3423
Analysis of risk factors for low bone mineral density in inflammatory bowel disease.
Frei Pascal,Fried Michael,Hungerbuhler Vera,Rammert Christina,Rousson Valentin,Kullak-Ublick Gerd A
Digestion
BACKGROUND/AIM:Several risk factors have been suggested for osteoporosis which frequently occurs in inflammatory bowel disease (IBD) patients. We studied prevalence and risk factors for reduced bone mineral density (BMD) in IBD patients at the University Hospital of Zurich, Switzerland. METHODS:The BMD was determined by dual-energy X-ray absorptiometry at the lumbar spine and femoral neck in 88 IBD patients (55 with Crohn's disease, 30 with ulcerative colitis, and 3 with indeterminate colitis). Z scores were obtained by comparison with age- and sex-matched normal values, and T scores by comparison with sex-matched healthy young adults. Osteopenia and osteoporosis were defined according to the WHO guidelines. Predictive factors for BMD were analyzed by group comparison and stepwise regression analysis. RESULTS:Osteopenia was present in 43% of the patients at the lumbar spine and in 42% of them at the femoral neck. Osteoporosis was present in 14% of the patients at the lumbar spine and in 5% of them at the femoral neck. At the lumbar spine, stepwise regression analysis showed that body mass index, age, number of bowel resections, topic steroids, and azathioprine correlated with the Z scores. Cumulative steroid dose, topic steroids, age and bowel resection were found to be predictors for a pathological T score. At the femoral neck, regression analysis showed that body mass index, age, topic steroids, and azathioprine correlated with the Z scores. Only a low body mass index was a significant predictor for pathological femoral T scores. CONCLUSIONS:Osteopenia and osteoporosis are commonly found in IBD patients. Steroid treatment and bowel resection were significant risk factors for osteoporosis of the lumbar spine. However, disease-inherent factors also appear to confer a major risk, indicating that the BMD should be determined in all IBD patients, irrespective of steroid treatment.
10.1159/000092013
Efficacy of calcitriol in treating glucocorticoidinduced osteoporosis in patients with nephrotic syndrome: an open-label, randomized controlled study.
Chen Yi,Wan Jian-Xin,Jiang De-Wen,Fu Bin-Bin,Cui Jiong,Li Gui-Fen,Chen Cai-Ming
Clinical nephrology
OBJECTIVE:To evaluate the efficacy and safety of calcitriol in the prevention and treatment of glucocorticoid-induced osteoporosis. METHODS:66 patients treated with glucocorticoids (GC) for primary nephrotic syndrome (NS) were randomly assigned to 3 groups. Groups were designated as follows: calcitriol alone (n = 22), calcitriol plus calcium carbonate (n = 23), or calcium carbonate alone (n = 21). Serum markers of bone metabolism and bone mineral density (BMD) were tested at 3 different time points: the initiation of GC treatment (baseline), 12 weeks, and 24 weeks after the initiation of treatment. RESULTS:Levels of serum 25-hydroxy vitamin D, serum osteocalcin, and total serum collagen type N-terminal extension of the peptide were significantly decreased following GC therapy (p < 0.05). β-collagen serum-specific sequences were significantly increased following GC therapy. The above-mentioned changes were less dramatic in patients treated with calcitriol, although the differences were significant (p < 0.05). Changes in serum levels of calcium, phosphorus, alkaline phosphatase, and parathyroid hormone (PTH) were not significant. 24 weeks after the initiation of treatment, BMD of the lumbar spine and femoral bone significantly decreased in all of 3 groups. However, patients who received calcitriol had significantly higher BMD of the lumbar spine than patients who received calcium carbonate alone (calcitriol plus calcium carbonate vs. calcium carbonate alone: 0.82 ± 0.19 g/cm2 vs. 0.62 ± 0.23 g/cm2 p < 0.05; calcitriol vs. calcium carbonate alone 0.805 ± 0.203 g/cm2 vs. 0.615 ± 0.225 g/cm2 p < 0.05), respectively. No serious adverse events were observed. CONCLUSION:Calcitriol may be more effective than calcium carbonate in preventing and treating GC-induced osteoporosis in patients with NS.
10.5414/CN108473
Statin therapy decreases the risk of osteonecrosis in patients receiving steroids.
Pritchett J W
Clinical orthopaedics and related research
Osteonecrosis is a devastating complication of systemic steroid use. Prolonged steroid use produces a hyperlipidemic state in most patients and puts them at risk for osteoporosis and osteonecrosis. The fat content within the femoral head increases, resulting in increased intracortical pressure that may lead to sinusoidal collapse and osteonecrosis. Statins are lipid-clearing agents that dramatically reduce lipid levels in blood and tissues. Statins are widely used to prevent cardiovascular disease and have been shown to reduce the adverse effects of steroids on lipid metabolism. The purpose of this study was to determine whether the use of statin drugs affects later development of osteonecrosis in patients receiving steroids. The records of 284 patients who were taking statin drugs at the time they were started on high dose steroids were examined to determine whether osteonecrosis had developed. The patients remained on statin drugs during the entire time of steroid exposure. Magnetic resonance imaging scans were used to verify the osteonecrosis unless it was visible by radiograph. After an average of 7.5 years (minimum followup, 5 years), only three patients (1%) from the group had osteonecrosis develop. This 1% incidence is much less than the 3% to 20% incidence usually reported for patients receiving high-dose steroids. Statins may offer some protection against having osteonecrosis develop when steroid treatment is necessary.
10.1097/00003086-200105000-00022
[Clinical characteristics and risk factors in 118 patients with systemic lupus erythematosus and osteonecrosis].
Li N N,Chen Y J,Leng X M,Zhang W,Tian X P,Zhao Y,Zeng X F
Zhonghua nei ke za zhi
To investigate the clinical characteristics and risk factors for osteonecrosis (ON) in patients with systemic lupus erythematosus (SLE). This is a case-control study. A total of 118 patients diagnosed with SLE complicated with ON (study group) were retrospectively analyzed between 2014 and 2019. Gender, age, and course matched 118 SLE patients without ON were selected as controls. Clinical manifestations, laboratory findings, medical history, and treatments were recorded and analyzed. Among 118 patients, the male to female ratio was 20 to 98 with a median age of 27 years and course of disease 1-168 months. Compared with the control group, the study group presented a longer cumulative duration of glucocorticoid therapy [36.5 (0-168) months vs. 19.0(0-168) months on average, <0.05], a higher incidence of osteoporosis (29.7% vs. 4.2%, <0.001), a higher frequency of immune-suppressive therapy (83.9% vs. 64.4%, =0.035), more organs involveed [median 2 (0-5) vs. 1 (0-4)], and a higher SLE disease activity index (SLEDAI) (14.22±7.40 vs. 11.63±6.11, <0.05) in univariate logistic regression. The control group had a higher rate of positive Coombs test (39.8% vs. 7.6%, <0.05). No statistical difference on methylprednisolone (MP) pulse therapy (>0.05) was observed. Multivariate logistic regression suggested that SLEDAI (= 1.070, 95% 1.026-1.116, <0.005), osteoporosis (=10.668, 95% 3.911-29.103, <0.001) and a positive Coombs test(=0.492, 95% 0.266-0.910, <0.05) were related to the development of ON in SLE patients. A higher disease activity and the presence of osteoporosis are associated with an increased risk of ON in patients with SLE, and positive Coombs test seems a protective factor of ON.
10.3760/cma.j.cn112138-20200916-00818
[STEROID-INDUCED OSTEONECROSES OF FEMORAL HEAD].
Chikvatia L,Avazashvili N,Obgaidze G,Zakradze D
Georgian medical news
Avascular necrosis of the femoral head is a multifactorial disease with progressive development of severe secondary coxarthrosis. There are two types of necroses - secondary and idiopathic. The pathogenesis of necrosis is associated with local blood circulation disorders, coagulopathies and violation of bone tissue regeneration. Usage of Steroids is one of the most often and important causes of non-traumatic osteonecrosis of the femoral head. Postulated pathogenetic mechanisms of steroid-induced osteonecrosis (ON) of the femoral head includes fat cell hypertrophy, fat emboli and intravascular coagulation. MRI stays the main diagnostic method for detection of osteonecrosis in the early stages. Preservation of the native hip is the goal of treatment in young and active patients. Early diagnosis and intervention prior to collapse of the femoral head is the key to a successful outcome of joint preserving procedures. There are no specific biomarkers for diagnostic of ON and NO "golden standard" for its treatment, and frequently a multidisciplinary approach becomes necessary. Joint replacement procedure remains as a main method of treatment after failure of joint preserving procedures and in cases of the late-stages of ON, involving collapse of the femoral head and degenerative changes of the acetabulum. More recent reports of hip replacement surgeries while osteonecrosis of the femoral head, have shown excellent results, but implant longevity and following revision surgeries, still remain an outstanding problem. In this article, there is described one of the latest clinical cases of the steroid induced avascular necroses of femoral head, which took place in our clinic. Positive clinical outcome, that means full physical and social rehabilitation of the patient, treated by total hip replacement confirms effectiveness of this method in treatment of above mentioned pathology.
Does statin usage reduce the risk of corticosteroid-related osteonecrosis in renal transplant population?
Ajmal Muhammad,Matas A J,Kuskowski Michael,Cheng Edward Y
The Orthopedic clinics of North America
The relationship between corticosteroids and osteonecrosis is well known. Limited data suggest that statins modulate cholesterol metabolism and may protect against osteonecrosis. The authors analyzed their prospective renal transplant database to determine if statin usage reduces the incidence of corticosteroid-related osteonecrosis and identified 2,881 renal transplantation patients who met the entry criteria. Among 338 patients on statins, 15 (4.4%) developed osteonecrosis, versus 180 of 2,543 (7%) patients who were not on statins. Osteonecrosis-free survival was similar in patients with and without statin exposure.
10.1016/j.ocl.2009.01.004
Osteonecrosis of the femoral head: a prospective study with MRI.
Sakamoto M,Shimizu K,Iida S,Akita T,Moriya H,Nawata Y
The Journal of bone and joint surgery. British volume
We performed a prospective study using MRI to evaluate early necrosis of the femoral head in 48 patients receiving high-dose corticosteroids for the treatment of various autoimmune-related disorders. The mean interval from the initiation of corticosteroid therapy to the first MRI examination was 2 months (0.5 to 6). MRI was repeated, and the mean period of follow-up was 31 months (24 to 69). Abnormalities were found on MRI in 31 hips (32%). The initial changes showed well-demarcated, band-like zones which were seen at a mean of 3.6 months after initiation of treatment with steroids. In 14 of these hips (45%) there was a spontaneous reduction in the size of the lesions about one year after treatment had started, but there was no further change in size with a longer follow-up.
Effect of blood biochemical factors on nontraumatic necrosis of the femoral head : Logistic regression analysis.
Zhang Ying,Sun Ruibo,Zhang Leilei,Feng Lizhi,Liu Youwen
Der Orthopade
OBJECTIVE:This case-control study aimed to identify the risk factors of nontraumatic necrosis of the femoral head (NONFH). METHODS:In all, 242 patients with NONFH treated at the hip disease research center of our hospital between March 2012 and October 2015 were included. After excluding 19 patients with tumor or tuberculosis, 223 patients were enrolled. Controls comprised 223 healthy persons selected from our hospital database. Single-factor variance analysis and t test were performed to select the index of statistical significance. The 95% confidence interval (95% CI) and normal range of the selected indicators were compared, and abnormal related indexes were selected from the femoral head necrosis group. The selected indicators were based on the increase or decrease to locate the risk indicators and render their corresponding assignment. Logistic regression analysis of the risk factors was performed after the assignment. RESULTS:The necrotic group of patients with decreased carbon dioxide combining power (COCP), increased total cholesterol, increased low-density lipoprotein, and decreased high-density lipoprotein levels had statistically significant partial regression coefficient values and the odds ratios were 73.5 (95% CI 24.59-219.74), 7.15 (3.51-14.85), 633.07 (121.7-3304.78), and 20.11 (9.36-43.8), respectively, indicating that these are strong risk factors for NONFH. CONCLUSIONS:Abnormal lipid metabolism is a strong risk factor of NONFH. Lipid examination can be used as a screening tool for NONFH in high-risk populations, for alcoholism, and many hormone applications. The decreased COCP was associated with NONFH, and bone microcirculation was considered to possibly lead various conditions such as ischemia and hypoxia-related bone metabolic acidosis. However, further study is needed.
10.1007/s00132-017-3408-4
Correlation between an ABO Blood Group and Primary Femoral Head Necrosis: A Case-Control Study.
Yang Shu-Yan,Zeng Ling-Yuan,Li Chao,Yan Hong
Orthopaedic surgery
OBJECTIVE:To investigate the relationship between primary femoral head necrosis (ONFH) and an ABO blood group. METHODS:This study was a retrospective case-control trial. An analysis of the clinical data of an ABO blood group with 516 patients (case group) with ONFH and 489 limb-fracture patients (control group) without previous hip pain was obtained from the Second Hospital of Shanxi Medical University from November 2015 to November 2018. The clinical data included gender, age, height, weight, a history of smoking, alcohol abuse, prior medical history, hormone use, and ABO blood type. A logistic regression model was used for univariate and multivariate analysis. RESULTS:From November 2015 to November 2018, there were 267 males and 249 females in the 516 cases of ONFH in the case group. The control group included 289 males and 200 females. In terms of age, the average age of the case group was significantly lower than that of the control group. In terms of body mass index (BMI), the BMI of the case group was significantly higher than that of the control group (P < 0.05). From the previous medical history of patients in the two groups (coronary heart disease, hypertension, cerebrovascular disease, diabetes, and peripheral vascular disease), there was no significant difference between the two groups from a statistical perspective (P < 0.05). However, according to the risk factors of ONFH (smoking, alcohol abuse, hyperlipidemia, and hormone-use history), there were significant differences between the case group and the control group. There was no statistical difference in the quantitative distribution ratio of the four blood types - A, B, O, and AB - between the case group and the control group. The outcomes of logistic multiple regression analysis presented that there was no significant correlation between the occurrence of ONFH and blood type A, B, AB, and O (P > 0.05). However, there are significant differences in the disease progression between the different blood types. There was a significant difference in the progression of disease between type A and type O. Among them, patients with ONFH and type A blood had the fastest progression with an average of 2.318 years, and the slowest progression was found in type O blood with an average of 5.15 years. CONCLUSIONS:The ABO blood group has no correlation with the occurrence of ONFH, but the ABO blood type is closely related to the disease progression of ONFH.
10.1111/os.12628
Magnetic resonance imaging identifies early femoral head ischemic necrosis in patients receiving systemic glucocorticoid therapy.
Kalunian K C,Hahn B H,Bassett L
The Journal of rheumatology
Ischemic necrosis of bone, a frequent complication of glucocorticoid therapy, can result in disability due to bone collapse and destruction. Some investigators have suggested that core decompression of involved marrow benefits patients with early disease. As radiographs are normal in early disease, identification of patients has been dependent on nonspecific radionuclide imaging or more specific but invasive hemodynamic studies. In order to define a sensitive, noninvasive diagnostic tool, we compared magnetic resonance imaging (MRI) to 99mtechnetium diphosphonate and 99mtechnetium sulfur colloid scintigraphy in 10 consecutive glucocorticoid treated patients with suspected femoral head ischemic necrosis of bone but normal roentgenograms. MRI identified the ischemic necrosis (defined by characteristic radiographic progression or histology) in 13/13 femoral heads. Both scans together identified only 5/13 of the cases. Only 1/20 osteoarthritic femoral heads had MRI patterns similar to those seen in ischemic necrosis of bone. We conclude that MRI is a sensitive and relatively specific method to detect early femoral head ischemic necrosis of bone.
Prevention of steroid-induced osteonecrosis of femoral head in systemic lupus erythematosus by anti-coagulant.
Nagasawa K,Tada Y,Koarada S,Tsukamoto H,Horiuchi T,Yoshizawa S,Murai K,Ueda A,Haruta Y,Ohta A
Lupus
Although osteonecrosis of femoral head (ONF) is one of the serious complications in systemic lupus erythematosus (SLE) associated with corticosteroid therapy, there has been few trials of prevention of ONF described. We aimed to prevent ONF in steroid-treated SLE patients using anticoagulant, warfarin, conducting a multicenter prospective study. Sixty newly diagnosed SLE patients requiring 40 mg/day or more prednisolone were alternately assigned to either of two groups; a warfarin group and a control one. Warfarin (1 to approximately 5 mg/day) was started together with the beginning of steroid therapy and continued at least for three months. Patients were observed for the development of silent ONF by magnetic resonance imaging (MRI) and symptomatic ONF by plain radiography for over five years. The warfarin group consisted of 31 patients (62 hips) and the control one 29 patients (58 hips). Silent ONF developed in 13 hips (21%) and 19 hips (33%) in the warfarin group and the control group, respectively (P = 0.13). On the other hand, warfarin tended to prevent symptomatic ONF; only three hips of 62 (4.8 %) in the warfarin group and eight hips of 58 (14%) in the control group (P = 0.08) developed silent ONF. It was also found that silent ONF developed, if it did, very early; within three months in 16 of 18 patients (89%). Among risk factors for silent ONF, steroid pulse therapy was most outstanding and it seemed to overcome the effect of warfarin. Taken together, for the time being, anti-coagulant therapy, if not significantly sufficient, may be of use for the prevention of steroid-induced ONF in SLE. We consider that this study added to important evidence for the pathogenesis and prevention of ONF.
10.1191/0961203306lu2311oa
Very early development of steroid-associated osteonecrosis of femoral head in systemic lupus erythematosus: prospective study by MRI.
Nagasawa K,Tada Y,Koarada S,Horiuchi T,Tsukamoto H,Murai K,Ueda A,Yoshizawa S,Ohta A
Lupus
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) ONE 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 ONE 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.
10.1191/0961203305lu2103oa
[A prospective study of steroid-induced osteonecrosis by MRI screening].
Sakamoto M
Nihon Seikeigeka Gakkai zasshi
The first aim of this study was to investigate the efficacy of magnetic resonance imaging (MRI) for detecting multiple osteonecrosis, and the second aim was to determine the onset and early development of the osteonecrotic lesions by the MRI. MRI was employed to examine for osteonecrosis in the hip, knee, ankle and shoulder in 140 patients who received high-dosage corticosteroids (over 30 mg of prednisolone per day) for their condition. Osteonecrosis was indicated by the presence of band-like lesions on the MRI. In 33 hips of 20 patients, hip prostheses had already been performed because of osteonecrosis in the femoral head. One hundred and twenty (86%) of the 140 patients had affected joints. MRI showed osteonecrotic lesions in 176 hips of 99 patients, in 143 knees of 77 patients, in 46 ankles of 30 patients and in 44 shoulders of 25 patients. Osteonecrosis in the knee occurred very frequently, so MRI was useful to examine the knee to detect multiple osteonecrosis. When there was no osteonecrosis in either the hip or the knee, then osteonecrosis in the ankle or shoulder was rare. We concluded that MRI screening of both the hip and knee was sufficient to detect multiple osteonecrosis. A prospective study of osteonecrosis was carried out. A total of 35 patients who had undergone a first MRI examination within 6 months from high-dosage corticosteroid administration were followed up by MRI. Characteristic MRI findings of osteonecrosis were present in 13 patients (37%) involving 11 hips (16%) and 18 knees (26%). In the remaining 22 patients, MRI showed no abnormal findings. The appearance of band-like lesions on MRI occurred at approximately 3 months from the corticosteroid administration. In 4 hips of 2 patients and in 12 knees of 7 patients, the observed band-like lesions gradually diminished until approximately 1 year from the administration, but since then the band-like lesions showed no further reduction on MRI.
Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment.
Koo K-H,Kim R,Kim Y-S,Ahn I-O,Cho S-H,Song H-R,Park Y-S,Kim H,Wang G-J
Clinical rheumatology
Patients who require long-term steroid use are at risk for the development of osteonecrosis. However, the risk period for developing osteonecrosis of the femoral head has not yet been defined. The authors attempted to determine the onset of osteonecrosis of the femoral head following steroid treatment. Medical record data of patients with steroid-related osteonecrosis of the femoral head from four university hospitals were reviewed. Information was collected regarding the duration and dose of steroid use for patients who were diagnosed at the early stage by magnetic resonance imaging (MRI) without positive findings on plain radiographs (Association Research Circulation Osseous stage I osteonecrosis). Twenty-two patients were diagnosed at Association Research Circulation Osseous stage I. There were eight male and 14 female patients ranging in age from 17 to 60 years (mean 33). The total dose of steroid, which was used until the time of detection of osteonecrosis by MRI, ranged from 1800 to 15 505 mg prednisolone or its equivalent (mean 5928 mg). The period from the start of steroid treatment to the diagnosis by MRI ranged from 1 month to 16 months (mean 5.3 months). Twenty-one of 22 patients were diagnosed within 12 months of the initiation of steroid treatment. The duration of steroid treatment within this period ranged from 1 month to 12 months (mean 4.5 months). There may be a risk period of 12 months for developing femoral head osteonecrosis in patients receiving long-term steroid treatment. Close observation and more aggressive screening are recommended within the first year of long-term steroid treatment to prevent advanced osteonecrosis of the femoral head.
10.1007/s100670200078
BOLD-MRI early detect femoral head osteonecrosis following steroid-treated patients.
Li Jing,Wang Jingjing,Zhao Jihua,Yuan Bin,Xing Liming,Tang Fengming,Liu Lei,Lu Mingming,Zhang Quan,Zhao Jun,Gu Peng,Li Jianhui,Zhang Zhuoli,Sun Chong,Zhang Yu,Yuan Fei
Medicine
The purpose of the study is to evaluate the feasibility of blood oxygenation level-dependent MRI (BOLD-MRI) to early detect the femoral head osteonecrosis (FHON). One hundred twelve patients were recruited who had received steroid treatment. The normal control group included 10 volunteers with 20 hips. MRI examinations were performed in all patients following up at 1, 4 to 5, 7 to 8, and 12 to 13 months after steroid therapy. With the section cross as the biggest lesion in coronal images, we set 6 regions of interest (ROIs) per section to analyze the morphological performance of routine MRI sequences and the differences of R2* values and their dynamic changes of BOLD-MRI between the control and the FHON group. A total of 15 hip joints were diagnosed with FHON. Seven right hips and 8 left hips were affected. In the first and second MRI examinations, the area of the lesion for both conventional MRI and BOLD-MRI R2* mapping was difficult to distinguish the lesion border. However, at the third and the fourth MRI examinations, some of the affected regions for R2* mapping were larger than those in conventional sequences for the same patient. BOLD-MRI has some significant advantages in early detecting FHON over conventional MRI techniques and it can be feasible noninvasive tool for detecting and evaluating FHON after steroid therapy.
10.1097/MD.0000000000008401
Early diagnosis and treatment of steroid-induced osteonecrosis of the femoral head.
Fu Weimin,Liu Baoyi,Wang Benjie,Zhao Dewei
International orthopaedics
OBJECTIVE:This study aims to investigate the early diagnosis and treatment of steroid-induced osteonecrosis of the femoral head. PATIENTS AND METHODS:From January 2010 to January 2014, a total of 350 patients, who required the use of large amounts of hormones, were enrolled into the study. These patients were followed up every three months after starting the hormone therapy. A total of 62 cases were screened, among which nine cases were asymptomatic. Furthermore, 38 patients were diagnosed as stage I and were given low-molecular weight heparin (LMWH) and vasodilator drugs. Moreover, 22 cases were diagnosed as stage IIa/b and underwent core decompression. In addition, two cases were diagnosed as stage IIc and underwent pedicled bone transplantation. During the follow-up period, ARCO staging was used for radiological evaluation, the HHS score was applied to evaluate for clinical efficacy, and SPSS 22.0 statistical software was used for the data analysis. RESULTS:A total of 60 patients were followed up for 24 months. Among these patients, 38 patients were diagnosed with ARCO stage I and underwent systematic therapy. No progress was found in 29 cases (76.3%). Furthermore, three cases progressed to stage IIb (7.8%), four cases progressed to stage IIc (10.5%), two cases progressed to stage III and IV, respectively (2.6%), and 16 cases (80%) did not progress after core decompression. In the 16 cases at stage IIa and four cases at stage IIb, and four cases (20%) progressed in stage III. The HHS score of stage I was 80.42 ± 3.25 before follow-up, while the HHS score was 86.46 ± 8.54 after follow-up, and the difference was statistically significant (P < 0.05). Furthermore, the HHS score of patients with stage IIa/b was 70.38 ± 4.62 before follow-up, while the HHS score was 80.28 ± 6.72 after follow-up, and the difference was statistically significant (P < 0.01). CONCLUSION:MRI remains as the most effective method for the non-invasive diagnosis of osteonecrosis, at present. Enhanced MRI may be able to detect early osteonecrosis, but further research is needed. Drug treatment and core decompression can achieve satisfactory results at the early stage.
10.1007/s00264-018-4011-y
[MODEL ESTABLISHMENT, MRI AND PATHOLOGICAL FEATURES OF EARLY STEROID-INDUCED AVASCULAR NECROSIS OF FEMORAL HEAD IN RABBIT].
Zhang Liyan,Sun Xin,Tian Dan,Xu Rui,Lei Hao,Al Jinhui,Zhao Bo,Chen Jiying,Chai Wei,Ma Shoucheng,Liu Weijia,Shen Siyuan
Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery
OBJECTIVE:To establish an rabbit model of early steroid-induced avascular necrosis of the femoral head (SANFH) and evaluate its validity with MRI and pathological examination. METHODS:Twenty 6-month-old rabbits (weighing, 2-3 kg) were randomly divided into 2 groups (control group and model group), 10 rabbits in each group. Dexamethasone sodium phosphate solution (10 mg/kg) was injected into bilateral gluteus in model group, and the same amount of saline was injected in control group, every 3 days for 14 times. General observation was done after modelling. Osteonecrosis was verified by pathological observation and MRI findings at 6 weeks. RESULTS:After 6 weeks, rabbits did not show obvious changes in control group; increased hair removal, decreased food intake, and slight limp were observed in model group. The MRI results showed normal shape of the bilateral femoral head and no abnormal signals in control group; irregular shape of the bilateral femoral head and a slice of irregular abnormal signals were observed, and necrosis and cystolization of the subchondral bone and sparse changes of trabecular bone were shown in model group. General observation from coronal section of femoral head showed smooth red cartilage surface in control group; on the contrary, the cartilage surface of the femoral head became dull, thin even visible hemorrhage under articular cartilage and necrosis of the femoral head were observed. The histopathological examination indicated that trabecular bone of the femoral head in control group was massive, thick, and close and osteocytes in the bone lacunae had normal shapes. The osseous trabecular became thinner and broken; karyopyknosis of osteocytes and bone empty lacunae could be obviously seen in model. group. The rates of empty lacunae were 8.0% ± 0.5% in control group and 49.0% ± 0.3% in model group, showing significant difference (t = 21.940, P = 0.000). CONCLUSION:Establishing a model of early SANFH through injecting short-term, shock, and high dose of dexamethasone, and it can been evaluated effectively with MRI and pathological examination.
Early detection of steroid-induced femoral head necrosis using Tc-Cys-Annexin V-based apoptosis imaging in a rabbit model.
Wang Xiaolong,Li Jianbo,Man Da,Liu Rui,Zhao Jianmin
Molecular medicine (Cambridge, Mass.)
BACKGROUND:At present, the early diagnosis of femoral head necrosis mainly relies on Magnetic resonance imaging (MRI), and most early patients are difficult to make an accurate diagnosis. Therefore, to investigate the early diagnostic value of Tc-Cys-Annexin V Single-photon emission computed tomography (SPECT) imaging were compared with MRI in rabbit models of steroid-induced femoral head necrosis. METHODS:The animal model of steroid-induced femoral head necrosis (SIFHN) was established in 5-month-old healthy New Zealand white rabbits by injecting horse serum into ear vein and methylprednisolone into gluteal muscle, the purpose of modeling is to simulate the actual clinical situation of SIFNH. Tc-Cys-Annexin V SPECT imaging and MRI were performed at 2nd week, 4th week, and 6th week after modeling. After that, histopathology was used to verify the success of modeling. Apoptosis was detected by transmission electron microscopy (TEM) and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assay (TUNEL). RESULTS:At 2 weeks after the injection of hormone, Tc-Cys-Annexin V SPECT image showed abnormal radioactive uptake in the bilateral femoral head. And over time, the radioactivity concentration was more obvious, and the ratio of T/NT (target tissue/non-target tissues, which is the ratio of femoral head and the ipsilateral femoral shaft) was gradually increased. In the Tc-Cys-Annexin V SPECT imaging at each time point, T/NT ratio of the model group was significantly higher than that of the control group (P < 0.01); at 4 weeks after the injection of hormone, MRI showed an abnormal signal of osteonecrosis. At 2, 4, and 6 weeks after hormone injection, apoptosis was observed by TUNEL and TEM. CONCLUSIONS:Tc-Cys-Annexin V SPECT imaging can diagnose steroid-induced femoral head necrosis earlier than MRI, and has potential application value for non-invasively detecting early and even ultra-early stage of femoral head necrosis.
10.1186/s10020-020-00248-1
Avascular bone necrosis of the hip joint after solid organ transplantation in childhood: a clinical and MRI analysis.
Helenius Ilkka,Jalanko Hannu,Remes Ville,Tervahartiala Pekka,Salminen Sari,Sairanen Heikki,Holmberg Christer,Helenius Miia,Nietosvaara Yrjänä,Peltonen Jari
Transplantation
BACKGROUND:Aseptic osteonecrosis is a well-known complication after solid organ transplantation in adults. The occurrence of osteonecrosis in growing age has been studied after kidney transplantation, but no systematic evaluation of the joints has been reported after heart or liver transplantation in childhood. METHODS:A total of 196 children--93% of patients surviving kidney, liver and heart transplantation in Finland--participated in a cross-sectional survey. All children underwent a detailed clinical examination and filled out a questionnaire on musculoskeletal symptoms. Radiographs were taken in case of joint pain or abnormal clinical findings. In addition, magnetic resonance imaging (MRI) from the hips was taken on a random basis from 34 adult patients transplanted as a child. The mean follow-up time of all patients after transplantation was 9.2 years (range, 2.4 to 20.5 years). RESULTS:Twenty-eight (14%) patients reported prolonged joint or limb pain without previous trauma. Specific etiology for the limb pain was not found in 10 (5.1%) patients. Osteonecrosis seen in radiographs or MRI was noted in seven (3.6%) patients, of which three had received kidney, three liver, and one heart graft. Femoral head was affected in five patients, as well as talus bilaterally in one patient and lateral femoral condyle in one patient. All patients were older than 12 years at the time of diagnosis of the osteonecrosis. MRI of the hips of 34 randomly selected patients showed only one asymptomatic necrosis of the femoral head. CONCLUSIONS:Symptomatic osteonecrosis of the hip is uncommon after solid organ transplantation in childhood using the current immunosuppressive medications.
10.1097/01.tp.0000226062.36325.4b
Fate of untreated asymptomatic osteonecrosis of the femoral head.
Nam Kwang Woo,Kim Yong Lae,Yoo Jeong Joon,Koo Kyung-Hoi,Yoon Kang Sup,Kim Hee Joong
The Journal of bone and joint surgery. American volume
BACKGROUND:Magnetic resonance imaging has made it possible to detect asymptomatic lesions of osteonecrosis of the femoral head before abnormalities appear on plain radiographs. The extent of a necrotic lesion is known to be an important prognostic factor. In this study, we evaluated the fate of untreated asymptomatic osteonecrosis of the femoral head with an emphasis on the size of the lesion. We hypothesized that a lesion smaller than a certain size would not progress to symptomatic disease. METHODS:One hundred and five initially asymptomatic hips of patients with bilateral nontraumatic osteonecrosis of the femoral head who had been followed without any treatment for at least five years or until pain developed were enrolled in this study. The extent of a lesion was estimated according to the area of the lesion based on a two-dimensional analysis on magnetic resonance images or on plain radiographs at the time of diagnosis. RESULTS:Sixty-two hips became symptomatic, and forty-three hips remained asymptomatic for more than five years (average, eight years and seven months). Of the twenty-one hips with a small necrotic lesion (<30% of the area of the femoral head), one became painful; of the twenty-four hips with a medium-sized necrotic lesion (30% to 50% of the area of the femoral head), eleven became painful; and of the sixty hips with a large necrotic lesion (>50% of the area of the femoral head), fifty became painful. Forty-six of the sixty-two hips that became symptomatic required surgery. Pain developed within five years after the diagnosis in fifty-eight (94%) of the sixty-two symptomatic hips. CONCLUSIONS:No treatment appears to be necessary for asymptomatic necrotic lesions with an area smaller than 30% of the femoral head, as the vast majority of these lesions will remain asymptomatic for more than five years.
10.2106/JBJS.F.01582
Systematic analysis of classification systems for osteonecrosis of the femoral head.
Mont Michael A,Marulanda German A,Jones Lynne C,Saleh Khaled J,Gordon Noah,Hungerford David S,Steinberg Marvin E
The Journal of bone and joint surgery. American volume
BACKGROUND:Multiple classification systems for osteonecrosis of the hip have been developed to assist physicians in the diagnosis and treatment of this potentially debilitating disorder. The purpose of this analysis was to delineate the classification systems utilized in reports published since 1985 and, through a comparison of the most commonly used systems, to identify consistent factors that would allow for cross-publication comparisons to be made. METHODS:We performed a PubMed search for reports of outcome studies concerning treatment methods for osteonecrosis of the hip. All studies of reported outcomes with greater than ten patients were included in the analysis. Various classification systems were tabulated to determine usage frequencies. The four most commonly used systems were then analyzed to determine common factors used for classification. RESULTS:One hundred and fifty-seven studies were available for analysis. Sixteen major classification systems that made use of more than one radiographic factor were identified, and nine of these systems had one to five modifications reported throughout the literature. Additionally, eleven other systems made use of single factors obtained from either magnetic resonance imaging or anatomic data. The review revealed that four classification systems accounted for greater than 85.4% of the reported studies. Parameters for these four systems were stratified to allow for uniformity of patient or study evaluation. CONCLUSIONS:This analysis of the reported classification systems for osteonecrosis of the femoral head revealed several similarities between the most commonly used systems. An analysis of patients can be made with any of the four major systems if specific data are collected according to various magnetic resonance imaging and radiographic findings. This approach will allow for easier comparison of studies across different centers. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.
10.2106/JBJS.F.00457
The role of MR imaging in avascular necrosis of the femoral head.
Karantanas Apostolos H,Drakonaki Eleni E
Seminars in musculoskeletal radiology
Due to the pattern of its blood supply, the femoral head is particularly vulnerable to avascular necrosis (AVN). Nontraumatic AVN is a devastating disorder affecting young patients, and despite treatment it normally follows a progressive course toward a destructive osteoarthropathy. Magnetic resonance (MR) imaging is currently used in major classification systems solely for early detection of femoral head AVN when plain radiographs are normal. More recent data have shown that MR imaging may improve staging, investigate radiologically occult collapse, depict other causes of disability and pain, assess prognosis, and evaluate treatment. This article reviews the established and evolving role of MR imaging in patients at risk or with known femoral head AVN.
10.1055/s-0031-1278427
The role of imaging in diagnosis and management of femoral head avascular necrosis.
Manenti Guglielmo,Altobelli Simone,Pugliese Luca,Tarantino Umberto
Clinical cases in mineral and bone metabolism : the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases
The aim of this paper is to critically review the literature documenting the imaging approach in adult Femoral Head Avascular Necrosis (FHAVN). For this purpose we described and evaluated different radiological techniques, such as X-ray, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Nuclear Medicine. Plain films are considered the first line imaging technique due to its ability to depict femoral head morphological changes, to its low costs and high availability. CT is not a routinely performed technique, but is useful to rule out the presence of a subchondral fracture when MRI is doubtful or contraindicated. MRI is unanimously considered the gold standard technique in the early stages, being capable to detect bone marrow changes such as edema and sclerosis. It may be useful also to guide treatment and, as CT, it is a validated technique in follow-up of patients with FHAVN. Nuclear medicine imaging is mostly applied in post-operative period to detect graft viability or infective complications. More advanced techniques may be useful in particular conditions but still need to be validated; thus new research trials are desirable. In conclusion, X-ray examination is the first line approach, but lacks of sensitivity in early stage whereas MRI is indicated. CT easily depicts late stage deformation and may decrease MRI false positive results in detecting the subchondral fracture. However, the role of both Nuclear Medicine Imaging and advanced MR techniques in FHAVN still need to be investigated.
10.11138/ccmbm/2015.12.3s.031
[Bone marrow edema-differential diagnosis of the femoral head necrosis].
Stumpp P,Roth A
Der Orthopade
In patients with hip pain, clinical examination is of only restricted value in the differential diagnosis. Besides a patient's age, their medical history is often helpful in finding the correct diagnosis. Additionally, imaging can give valuable hints for excluding or validating a differential diagnosis. Nowadays, magnetic resonance imaging (MRI) is often used as a primary imaging modality in Germany. These MRIs show a bone marrow edema (BME) in many different pathologies. BME occurs in transitory bone marrow edema and outside of the atraumatic femoral head necrosis, concomitant with coxarthrosis, arthritis, herniation pit, and osteoid osteoma, amongst other conditions. This article describes several frequent differential diagnoses and gives hints on how to find the correct diagnosis.
10.1007/s00132-018-3621-9
[S3 Guideline. Part 1: Diagnosis and Differential Diagnosis of Non-Traumatic Adult Femoral Head Necrosis].
Bohndorf K,Beckmann J,Jäger M,Kenn W,Maus U,Nöth U,Peters K M,Rader C,Reppenhagen S,Roth A,
Zeitschrift fur Orthopadie und Unfallchirurgie
Non-traumatic femoral head necrosis (FHN) is primarily a disease of the middle-aged adult. Early diagnosis, at a time with lacking or minimal clinical symptoms, is mandatory to consider conservative therapy or joint preserving operations as a therapeutic option. The new German S3 guideline about diagnosis and therapy of FHN is a cooperative effort of five professional medical societies, overall headed by the Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). This review (part I/III) cites and explains the statements of the S3 guideline as agreed on the use of imaging methods for diagnosis of FHN. A diagnostic algorithm is presented. FHN clinically has to be considered in case of equivocal pain of a hip joint with a minimum of 6 weeks duration, when risk factors can be revealed, groin pain at clinical investigation, limping, pain or limitation of movement in case of load, and no obvious differential diagnoses. Is an FHN clinically suspected, primarily radiographs of the pelvis ap and a Lauenstein projection of the hip involved should be carried out. When the radiographs are normal, an MRI of the hips should follow routinely. MRI allows the diagnosis of FNH with high accuracy. Furthermore, MRI reveals the site and the size of the necrotic area involved and evaluates the integrity of the joint surface and subchondral fractures. When ARCO stage II (ARCO: Association Research Circulation Osseous) is diagnosed and MRI does not allow one to determine the joint surface with certainty, a CT of the hip joints should be performed. The S3 guideline explains and recommends the use of the ARCO classification. Although, this classification of 1993 is still largely based on radiographs, the pragmatic use of an "extended" version seems reasonable. Today, classical radiographic criteria like impression of the joint surface and subchondral fractures ("crescent sign") are better to be evaluated by MRI, in cases of subtle findings MRI is even surpassed by CT. The extent of the necrosis in the femoral head as well as the size of the surface area involved is best revealed with MRI. Additionally, in the era of cross sectional imaging a stage "0" seems obsolete. The guideline also addresses practically important considerations about the differential diagnosis of misleading MRI findings. This especially holds true for bone marrow oedema in the femoral head which may be misinterpreted. The differentiating features between FHN, transient bone marrow oedema and destructive arthropathy are discussed.
10.1055/s-0035-1545901
[Imaging and classification of avascular femoral head necrosis].
Bohndorf K,Roth A
Der Orthopade
Avascular femoral head necrosis (AVNFH) is difficult to diagnose on plain radiographs in early stages of the disease. Since early stages are often clinically occult, early use of MRI is required to rule out or verify a clinical suspicion. MRI and, in some cases, additional CT are the cornerstones of AVNFH diagnosis and classification. Anteroposterior radiography of the pelvis and a second plane of the involved hip remains the primary basic imaging examination for follow-up and to rule out other pathologies. Correct staging of adult disease has been shown to be the key factor in therapeutic decision-making. According to the German S3 guideline on diagnosis and treatment of AVNFH, use of the ARCO classification is recommended for staging. This paper presents the current status of diagnosis and classification of adult AVNFH. The criteria for ascribing disease to a particular ARCO stage are defined and critically discussed.
10.1007/s00132-018-3615-7
Pericollapse Stage of Osteonecrosis of the Femoral Head: A Last Chance for Joint Preservation.
Zhang Qing-Yu,Li Zi-Rong,Gao Fu-Qiang,Sun Wei
Chinese medical journal
OBJECTIVE:To propose a new definition of the pericollapse stage of osteonecrosis of the femoral head (ONFH) and review its significance in disease diagnosis and treatment selection. DATA SOURCES:A search for eligible studies was conducted in three electronic databases including PubMed, Cochrane Library, and Embase up to August 10, 2018, using the following keywords: "osteonecrosis", "prognosis", and "treatment". STUDY SELECTION:Investigations appraising the clinical signs, symptoms, and imaging manifestations in different stages of ONFH were included. Articles evaluating the prognosis of various joint-preserving procedures were also reviewed. RESULTS:The pericollapse stage refers to a continuous period in the development of ONFH from the occurrence of subchondral fracture to early collapse (<2 mm), possessing specific imaging features that mainly consist of bone marrow edema and joint effusion on magnetic resonance imaging (MRI), crescent signs on X-ray films, and clinical manifestations such as the sudden worsening of hip pain. Accumulating evidence has indicated that these findings may be secondary to the changes after subchondral fractures. Of note, computed tomography provides more information for identifying possible subchondral fractures than does MRI and serves as the most sensitive tool for grading the pericollapse lesion stage. The pericollapse stage may indicate a high possibility of progressive disease but also demonstrates satisfactory long- and medium-term outcomes for joint-preserving techniques. In fact, if the articular surface subsides more than 2 mm, total hip arthroplasty is preferable. CONCLUSIONS:The pericollapse stage with distinct clinical and imaging characteristics provides a last good opportunity for the use of joint-preserving techniques. It is necessary to separate the pericollapse stage as an independent state in evaluating the natural progression of ONFH and selecting an appropriate treatment regimen.
10.4103/0366-6999.244111
MRI-detected bone marrow changes within 3 weeks after initiation of high-dose corticosteroid therapy: a possible change preceding the subsequent appearance of low-intensity band in femoral head osteonecrosis.
Kubo Yusuke,Yamamoto Takuaki,Motomura Goro,Tsukamoto Nobuaki,Karasuyama Kazuyuki,Sonoda Kazuhiko,Hatanaka Hiroyuki,Utsunomiya Takeshi,Iwamoto Yukihide
Rheumatology international
Osteonecrosis of the femoral head is considered to occur early during the course of corticosteroid treatment. However, it remains unclear exactly how early it can develop after initiation of corticosteroid treatment. We report a case of osteonecrosis of the femoral head in which abnormal findings were observed on short-tau inversion recovery (STIR) sequence image performed 2 weeks and 4 days after initiation of high-dose corticosteroid therapy. A 45-year-old man with hemophagocytic syndrome was started on prednisolone, with a maximum dose of 40 mg/day. On day 13 after initiation of this corticosteroid therapy, he transiently experienced left hip pain with no apparent cause. STIR sequence image 5 days after the onset of pain revealed high-intensity bone marrow lesions at the femoral neck of both hips. At 3 months after initiation of corticosteroid therapy, T1-weighted magnetic resonance imaging revealed concave-shaped low-intensity bands, which corresponded to the preceding high-intensity lesions on both hips. Because of the subsequent progression to collapse of the left femoral head, he underwent prosthetic replacement surgery. The high-intensity lesions on STIR sequence image indicate the possibility that osteonecrosis can occur within 3 weeks after initiation of high-dose corticosteroid therapy.
10.1007/s00296-015-3346-6
Pathogenesis and natural history of osteonecrosis.
Assouline-Dayan Yehudith,Chang Christopher,Greenspan Adam,Shoenfeld Yehuda,Gershwin M Eric
Seminars in arthritis and rheumatism
BACKGROUND AND OBJECTIVES:Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment. METHODS:A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited. RESULTS:Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one. CONCLUSIONS:Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis. RELEVANCE:A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options.
Bone marrow edema around the hip in non-traumatic pain: dual-energy CT vs MRI.
Foti Giovanni,Faccioli Niccolò,Silva Ronaldo,Oliboni Eugenio,Zorzi Claudio,Carbognin Giovanni
European radiology
OBJECTIVES:To evaluate the diagnostic accuracy of dual-energy computed tomography (DECT) in identifying bone marrow edema (BME) around the hip joint in non-traumatic patients. METHODS:This prospective IRB-approved study was conducted between January 2019 and October 2019 and included 59 consecutive patients (18 males, 41 females; mean age 61.5 years, range 32-82) who were assessed by DECT and magnetic resonance imaging (MRI) within a 5-day period. Diagnostic accuracy values for diagnosing BME on a per-patient and on a per-partition-basis analysis were calculated for DECT images by two readers (R1 and R2, with 15 and 10 years of experience, respectively), using MRI as reference for diagnosis. Inter-observer agreements were calculated with k-statistics. A p value of < 0.05 was considered as statistically significant. RESULTS:MRI depicted BME in 44/59 patients (74.58%), with the involvement of 83/708 (11.72%) partitions. The sensitivity, specificity, and accuracy of R1 and R2 were 95.45% (42/44), 86.67% (13/15), and 93.22% (55/59) for R1, and 86.36% (38/44), 80.00% (12/15), and 84.75% (50/59) for R2. For both readers, the BME detection rate was higher in patients with severe edema (100%) in comparison to patients with mild edema (91.30% and 73.91%). In the partition-basis analysis, sensitivity, specificity, and accuracy ranges were 33.3 to 100%, 91.84 to 100%, and 88.14 to 100%, respectively. The inter-observer agreement for patients' analysis was substantial (k = 0.7065), whereas for partition analysis ranged from fair (k = 0.2976) to near-perfect (k = 1.000). CONCLUSION:DECT can accurately identify BME around the hip joint, in comparison to MRI. KEY POINTS:• DECT can accurately identify bone marrow edema around the hip joint in a cohort of non-traumatic patients. • The detection of bone marrow edema by means of DECT may help the radiologist to identify associated findings, including avascular necrosis of the femoral head and insufficiency or stress fractures. • In cases of patients suffering from groin pain with bone marrow edema identified by DECT, the concurrent reading of high-resolution conventional CT images may increase the confidence of diagnosis and/or reduce the reading time.
10.1007/s00330-020-06775-z
Radiographically negative avascular necrosis: detection with MR imaging.
Coleman B G,Kressel H Y,Dalinka M K,Scheibler M L,Burk D L,Cohen E K
Radiology
To correlate the morphologic appearance on magnetic resonance (MR) images of radiographically negative avascular necrosis (AVN) of the femoral head with that on computed tomographic (CT) and radionuclide scans, the radiographic and clinical records of 24 patients were reviewed retrospectively. In 18 patients the MR signal intensity features were monitored by means of serial imaging. All MR studies included T1-weighted (short repetition time [TR], short echo delay time [TE] ) imaging and T2-weighted imaging (long TR, long TE). Thirty-one hips were determined with MR to be involved by AVN; 27 were staged on the basis of signal intensity characteristics within the low-intensity rim. Core decompression was performed on 18 hips. Afterward, progression of disease occurred in only one hip. Fourteen of the 16 asymptomatic patients (88%) had early-stage focal lesions. CT scans were obtained in 15 patients and radionuclide scans in 21. Ten hips at radionuclide imaging and five at CT appeared normal when MR results were distinctly abnormal. MR can depict early radiographically negative AVN in asymptomatic individuals. At this early stage, the lesions in this series appear to be nonprogressive after treatment.
10.1148/radiology.168.2.3393676
[Principles of sonographic examination of the hip].
Schuler P
Ultraschall in der Medizin (Stuttgart, Germany : 1980)
The advantages of ultrasound in the diagnosis of congenital dislocation and dysplasia of the hip, compared with other imaging diagnostical methods are obvious, since an exact and early diagnosis of hip immaturity can be made. Using realtime sonography, it is possible to directly visualise the motion of the femoral head in the acetabulum and verify any instability of the joint. Especially hips which are classified as being in the critical range should always be examined dynamically to judge their grade of instability. This is necessary because these hips often show no pathology when examined clinically. Unlike radiography, hip sonography can diagnose the grade of hip maturation from the day of birth. Newborn screening can thus result in early detection and treatment of pathological hip joints. Since introducing routine newborn screening at our hospital, we have been able to achieve an earlier onset of therapy in 80% of the cases, within the first four weeks of age. The percentage of CDH diagnosed before and after introducing the newborn screening did not differ. Babies which are classified as being in the "risk group" were followed up regularly. Subsequent to the dynamic examination of the hip, problems of describing the arthrosonographic anatomy of the hip are discussed.
10.1055/s-2007-1011651
Avascular necrosis of the femoral head: high-field-strength MR imaging with histologic correlation.
Lang P,Jergesen H E,Moseley M E,Block J E,Chafetz N I,Genant H K
Radiology
Magnetic resonance (MR) images, contact radiographs, and histologic sections of six femoral head specimens with avascular necrosis were correlated. A low-signal-intensity band or ring represented the repair tissue interface surrounding a high-signal-intensity necrotic marrow segment. Large segmental areas of low signal intensity were observed on T1-weighted images when the lesion consisted of necrotic bone with amorphous marrow debris and adjacent thickened trabecular bone with mesenchymal repair tissue infiltration. On intermediate-weighted images, however, mesenchymal repair tissue, which was located inferior to the necrotic zone, increased markedly in signal intensity, permitting distinction from low-intensity necrotic bone with amorphous marrow debris. When trabecular thickening with collapse predominated, segmental areas of low signal intensity with both sequences were found. MR signal intensities used in combination with anatomic configuration and location may provide information of potential therapeutic importance regarding tissue composition and stage of disease.
10.1148/radiology.169.2.3175001
Morphological variants to predict outcome of avascular necrosis in developmental dysplasia of the hip.
Pollet Virginie,Bonsel Joshua,Ganzeboom Britt,Sakkers Ralph,Waarsing Erwin
The bone & joint journal
AIMS:The most important complication of treatment of developmental dysplasia of the hip (DDH) is avascular necrosis (AVN) of the femoral head, which can result in proximal femoral growth disturbances leading to pain, dysfunction, and eventually to early onset osteoarthritis. In this study, we aimed to identify morphological variants in hip joint development that are predictive of a poor outcome. METHODS:We retrospectively reviewed all patients who developed AVN after DDH treatment, either by closed and/or open reduction, at a single institution between 1984 and 2007 with a minimal follow-up of eight years. Standard pelvis radiographs obtained at ages one, two, three, five, and eight years, and at latest follow-up were retrieved. The Bucholz-Ogden classification was used to determine the type of AVN on all radiographs. Poor outcome was defined by Severin classification grade 3 or above on the latest follow-up radiographs and/or the need for secondary surgery. With statistical shape modelling, we identified the different shape variants of the hip at each age. Logistic regression analysis was used to associate the different modes or shape variants with poor outcome. RESULTS:In all, 135 patients with AVN were identified, with a minimum of eight years of follow-up. Mean age at time of surgery was 7.0 months (SD 0.45), and mean follow-up was 13.3 years (SD 3.7). Overall, 46% had AVN type 1 while 54% type 2 or higher. More than half of the patients (52.6%) had a poor outcome. We found 11 shape variants that were significantly associated with a poor outcome. These shape variants were predominantly linked to AVN type 2 or higher. CONCLUSION:Specific morphological characteristics on pelvis radiographs of AVN hips were predictive for poor outcome, at a very young age. There was an overall stronger association to Bucholz-Ogden types 2-3-4 with the exception of two modes at age two and five years, linked to AVN type 1. Cite this article: 2021;103-B(5):999-1004.
10.1302/0301-620X.103B5.BJJ-2020-1485.R1
Musculoskeletal applications of nuclear magnetic resonance.
Moon K L,Genant H K,Helms C A,Chafetz N I,Crooks L E,Kaufman L
Radiology
Thirty healthy subjects and 15 patients with a variety of musculoskeletal disorders were examined by conventional radiography, computed tomography (CT), and nuclear magnetic resonance (NMR). NMR proved capable of demonstrating important anatomic structures in the region of the lumbosacral spine. Lumbar disk protrusion was demonstrated in three patients with CT evidence of the disease. NMR appeared to differentiate annulus fibrosus from nucleus pulposus in intervertebral disk material. Avascular necrosis of the femoral head was demonstrated in two patients. The cruciate ligaments of the knee were well defined by NMR. Muscles, tendons and ligaments, and blood vessels could be reliably differentiated, and the excellent soft-tissue contrast of NMR proved useful in the evaluation of bony and soft-tissue tumors. NMR holds promise in the evaluation of musculoskeletal disorders.
10.1148/radiology.147.1.6828722
Diagnosis of avascular necrosis of the femoral head in patients treated for lymphoma.
Ratcliffe M A,Gilbert F J,Dawson A A,Bennett B
Hematological oncology
Avascular necrosis of bone (AVNB) is a well-known but rare complication of chemotherapy for lymphoma with a reported incidence ranging from 1 to 10 per cent. Early diagnosis is essential for optimal therapeutic management. Using MRI, the most sensitive means of detecting the earlier stages of AVNB, 100 patients treated with standard chemotherapy for lymphoma were assessed. Fifteen were found to have changes of AVNB, 10 with early changes but five with advanced segmental collapse of the femoral head. None with AVNB had more than the standard course of corticosteroids. Almost a quarter of the study group complained of joint pain during and/or after their treatment, a third of whom were found to have AVNB; a strong indicator to screen all those with pain. However, 40 per cent of those with AVNB were asymptomatic. The clinical significance of the 'silent hip' is yet to be elucidated.
10.1002/hon.2900130303
Avascular necrosis of the femoral head: morphologic assessment by MR imaging, with CT correlation.
Mitchell D G,Kressel H Y,Arger P H,Dalinka M,Spritzer C E,Steinberg M E
Radiology
To better understand the morphologic appearance of avascular necrosis (AVN) of the femoral head on magnetic resonance (MR) images (1.5 T) and computed tomographic (CT) scans, the records of 21 lesions were reviewed retrospectively. All MR imaging studies included T1-weighted images (T1WI) (repetition times [TR] of 400-1,000 msec, and echo times [TE] of 20-25 msec), and 15 included T2-weighted images (T2WI) (TR = 2,000-2,500 msec; TE = 60-80 msec). MR signal features of the lesions were compared with features on the corresponding CT scans. Abnormalities in the superoanterior aspect of the femoral head were noted on both image types in all 21 lesions but were more obvious on MR images in two. A characteristic margin of peripheral sclerosis seen on CT scans in 95% (20 of 21) of lesions corresponded to a line of low intensity on MR images. Fractures complicating AVN were seen in eight lesions at CT scanning. On T1WI, fractures were not clearly delineated. On T2WI, fractures were of high intensity but were depicted less clearly than on CT scans. Central signal intensity of the lesions on T1WI correlated with the presence or absence of fracture: 88% (seven of eight) of the lesions with fractures appeared less intense than fat, compared with only 8% (one of 13) of lesions without fractures (P less than .005). While MR imaging is a sensitive method for early diagnosis of AVN, CT scanning can more accurately identify fractures and is thus important for staging.
10.1148/radiology.161.3.3786725
Digital filtering of the bladder in SPECT bone studies of the pelvis.
Gillen G J,McKillop J H,Hilditch T E,Davidson J K,Elliott A T
Journal of nuclear medicine : official publication, Society of Nuclear Medicine
A data processing technique for the removal of bladder activity from single photon emission computed tomographic bone studies of the pelvis has been developed. The method involves the replacement of count values in the bladder on all projection views by data which are representative of the activity in surrounding structures. Reconstruction is then performed using the amended set of projection views. The method was tested by examining a group of 13 patients referred for investigation of avascular necrosis of the femoral head. Significant improvements in image quality were observed, particularly with respect to the level of artifact production, which increased the number of cases in which a confident and correct diagnosis was made.
Noninvasive methods of measuring bone blood perfusion.
Dyke J P,Aaron R K
Annals of the New York Academy of Sciences
Measurement of bone blood flow and perfusion characteristics in a noninvasive and serial manner would be advantageous in assessing revascularization after trauma and the possible risk of avascular necrosis. Many disease states, including osteoporosis, osteoarthritis, and bone neoplasms, result in disturbed bone perfusion. A causal link between bone perfusion and remodeling has shown its importance in sustained healing and regrowth following injury. Measurement of perfusion and permeability within the bone was performed with small and macromolecular contrast media, using dynamic contrast-enhanced magnetic resonance imaging in models of osteoarthritis and the femoral head. Bone blood flow and remodeling was estimated using (18)F-Fluoride positron emission tomography in fracture healing and osteoarthritis. Multimodality assessment of bone blood flow, permeability, and remodeling by using noninvasive imaging techniques may provide information essential in monitoring subsequent rates of healing and response to treatment as well as identifying candidates for additional therapeutic or surgical interventions.
10.1111/j.1749-6632.2009.05376.x
Femoral head avascular necrosis: CT assessment with multiplanar reconstruction.
Magid D,Fishman E K,Scott W W,Brooker A F,Arnold W P,Lennox D W,Siegelman S S
Radiology
Thirty-two patients with avascular necrosis (AVN) of the femoral head underwent imaging studies using computed tomography with multiplanar reconstructions (CT/MPR). Staging of the disease by means of CT/MPR images was compared with traditional staging by means of routine frontal and frog-leg lateral radiographs. CT/MPR examination upgraded staging in 30% of the hips studied and made significant contributions to patient management in 14 (54%) of 26 patients for whom both CT scans and plain-film radiographs were available for comparison. Asymptomatic and radiographically normal contralateral hips were found at CT study to have stage II or stage III AVN in four patients. Subtle alterations in trabecular patterns, joint spaces, femoral-head contours, and acetabula were well defined on CT/MPR studies in many cases; previously undetected or ill-defined abnormalities were frequently visualized. The major weight-bearing components of the hip (anterior and posterior acetabular columns, acetabular dome, and superior pole of the femur), which may be poorly defined on CT scans due to partial volume effects on the transaxial images, were best seen on the sagittal and coronal reconstructions. A new system for staging AVN is suggested.
10.1148/radiology.157.3.4059563
Segmental patterns of avascular necrosis of the femoral heads: early detection with MR imaging.
Markisz J A,Knowles R J,Altchek D W,Schneider R,Whalen J P,Cahill P T
Radiology
Thirty-two patients (64 hips) in whom avascular necrosis (AVN) of the femoral heads was highly suspected clinically were studied by magnetic resonance (MR) imaging, radionuclide bone scintigraphy, and conventional radiography. MR studies were positive for AVN in 37 hips, compared with 30 positive scintigraphic studies. In all cases in which scintigraphy and radiography were positive, MR imaging demonstrated decreased signal from the affected femoral heads, indicative of bone marrow disease. Imaging results were confirmed by biopsy or subsequent imaging appearances. In patients with negative initial scintigraphic and radiographic studies, the MR imaging criterion for a positive study was a moderately decreased bone marrow signal displaying segmental patterns within an otherwise normal-appearing femoral head on relatively T1-weighted images. In this series of high-risk patients, radionuclide scintigraphy had a sensitivity of 81%, compared with 100% for MR imaging. MR imaging should be the imaging modality of choice for early evaluation of bone marrow changes indicative of AVN.
10.1148/radiology.162.3.3809485
The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes.
Shin A Y,Morin W D,Gorman J D,Jones S B,Lapinsky A S
The American journal of sports medicine
The accuracy of magnetic resonance imaging of the hip was prospectively evaluated in 19 military subjects engaged in endurance training. These patients had hip pain, negative radiographs, and radionuclide bone scans consistent with femoral neck stress fracture. Twenty-two hips were identified as positive for femoral neck stress fracture by bone scan. Each patient underwent magnetic resonance imaging and 6-week follow-up plain radiographs of the hips. Magnetic resonance imaging studies differentiated femoral neck stress fractures from a synovial pit, iliopsoas muscle tear, iliopsoas tendinitis, obturator externus tendinitis, avascular necrosis of the femoral head, and a unicameral bone cyst. The follow-up radiographs were used to verify the diagnosis of stress fracture. The radiographs showed healing callus in patients with stress fractures. Patients with diagnoses other than stress fractures had no changes on follow-up radiographs. Magnetic resonance imaging studies were as sensitive and much more specific than bone scan in determining the cause of hip pain. Radionuclide bone scan had an accuracy of 68% for femoral neck stress fractures with 32% false-positive results; MRI was 100% accurate. Magnetic resonance imaging proved to be superior to radionuclide bone scanning in providing an early and accurate diagnostic tool that aided in the differential diagnosis of hip pain in the young endurance athlete.
10.1177/036354659602400209
Potential pitfalls of magnetic resonance imaging in the diagnosis of avascular necrosis.
Kulkarni M V,Tarr R R,Kim E E,McArdle C B,Partain C L
Journal of nuclear medicine : official publication, Society of Nuclear Medicine
Magnetic resonance (MR) imaging and radionuclide (RN) bone scans were performed in two patients with collagen vascular disease (CVD) to evaluate hip pains. In both patients RN bone scans demonstrated decreased radioactivity in the femoral heads, whereas, MR imaging was normal. Because early changes of avascular necrosis (AVN) frequently present as decreased radioactivity in the femoral head, special attempts were made to detect this decreased activity using pinhole collimator imaging. The diagnosis of AVN was confirmed surgically by venous pressure measurements. Abnormal RN bone scans representing decreased flow due to vasculitis in patients with CVD, may be more sensitive in the diagnosis of AVN before structural changes can be detected on MR studies.
Avascular necrosis of the hip: comparison of contrast-enhanced and nonenhanced MR imaging with histologic correlation. Work in progress.
Vande Berg B,Malghem J,Labaisse M A,Noel H,Maldague B
Radiology
In 15 hips with typical signs of avascular necrosis of the femoral head on plain radiographs and magnetic resonance (MR) images, gadolinium-enhanced spin-echo and fat-suppressed MR images were obtained and compared with nonenhanced T1- and T2-weighted images. Both enhanced and nonenhanced areas were consistently detected in the abnormal femoral heads. Enhanced areas showed a low signal intensity (SI) on T1-weighted MR images obtained before contrast material was administered and an intermediate to high SI on T2-weighted images. Nonenhanced areas showed an SI either identical (pattern 1) or hypointense (pattern 2) to that of fat on both sequences. Histologic correlation (six resected femoral heads) helped confirm that enhanced and nonenhanced areas corresponded respectively to viable and necrotic tissue. In most cases, SI analysis of nonenhanced T1- and T2-weighted images allows the differentiation of hypervascularized viable tissue from hypovascularized necrotic tissue of the sequestrum.
10.1148/radiology.182.2.1732963
Detection of femoral head avascular necrosis in adults by SPECT.
Collier B D,Carrera G F,Johnson R P,Isitman A T,Hellman R S,Knobel J,Finger W A,Gonyo J E,Malloy P J
Journal of nuclear medicine : official publication, Society of Nuclear Medicine
Twenty-one adult patients with the clinical diagnosis of avascular necrosis (AVN) of the femoral head were examined with radionuclide angiography, planar bone scintigraphy, and single photon emission computed tomography (SPECT). A final diagnosis of AVN was established for 15 symptomatic patients with a total of 20 involved hips. SPECT and planar bone scintigraphy were considered positive for AVN only if a photopenic bony defect could be identified. Using SPECT bone scintigraphy, 12 of 15 symptomatic patients and 17 of 20 involved hips (sensitivity of 0.85) were correctly identified, whereas with planar imaging only eight of 15 patients and 11 of 20 involved hips were detected. There were no false-positive diagnoses on SPECT or planar bone scintigraphy. In addition, hyperemia in the region of the proximal femoral metaphysis was demonstrated in six of 20 involved hips. It is concluded that by identifying a photopenic defect that is not evident on planar views, SPECT can contribute to the diagnosis of AVN of the femoral head. In addition, metaphyseal hyperemia appears to be a promising new scintigraphic sign of AVN worthy of further investigation.
The value of oblique angle reorientation in SPECT bone scintigraphy of the hips.
Krasnow A Z,Collier B D,Peck D C,Hellman R S,Dellis C J,Kir K M,Isitman A T
Clinical nuclear medicine
SPECT bone scintigraphy has been shown useful for detecting avascular necrosis (AVN) of the femoral heads. Because the femoral necks project in a 15-20 degree posterior angulation from the coronal plane, the femoral head is partially superimposed upon the acetabulum in standard coronal SPECT images. To avoid this problem, the authors now perform oblique angle reorientation of all hip SPECT studies. This new technique, which allows display of the hip in a more anatomic fashion and better definition of hip abnormalities, is described. No new data acquisition is needed, and only a small amount of extra time is required for reconstruction.
10.1097/00003072-199005000-00001
Advanced hip osteoarthritis: magnetic resonance imaging aspects and histopathology correlations.
Leydet-Quilici H,Le Corroller T,Bouvier C,Giorgi R,Argenson J-N,Champsaur P,Pham T,de Paula A Maues,Lafforgue P
Osteoarthritis and cartilage
OBJECTIVES:To correlate magnetic resonance imaging (MRI) aspects of the femoral head with histological findings in advanced hip osteoarthritis (OA), with special emphasis on bone marrow edema (BME). METHODS:MRI was performed in patients with advanced hip OA scheduled for hip arthroplasty. Coronal T1-, fat-suppressed T2-, T1 with gadolinium intravenous injection sequences were obtained on a 1.5 T MR-scanner within 1 month before surgery. Coronal MR images corresponding to the ligamentum teres plane were analyzed by two independent readers blinded to histological data. Normal bone marrow, subchondral cyst, subchondral fracture, edema-like, necrosis-like, and necrosis MR patterns were reported on a synthesis scheme. After surgery, the femoral heads specimens were cut through the ligamentum teres plane and histologically analyzed for correlations. RESULTS:Twenty-three femoral heads were analyzed (female 56.5%, mean age 64.5 years). Edema-like MR pattern was correlated with histological (H) edema (Kappa (K): 0.77). Necrosis-like MR pattern was correlated with H fibrosis (K: 0.49) and with H necrosis (K: 0.24). Cyst MR pattern was correlated with H bone cysts (K: 0.58). Necrosis MR pattern corresponded to a mixture of histological lesions. Sensitivity and specificity of MRI varied from 26% to 80% and from 86% to 95% respectively. CONCLUSION:In advanced hip OA, the so-called "BME" MR lesion corresponds to a combination of edema, fibrosis, and necrosis at histopathology. When the classical "BME" is more specifically separated into edema-like and necrosis-like MR patterns, MR Imaging and histological findings show substantial agreement, with edema-like MR pattern mainly corresponding to histological edema.
10.1016/j.joca.2010.08.008
Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images.
Ha Yong-Chan,Jung Woon Hwa,Kim Jang-Rak,Seong Nak Hoon,Kim Shin-Yoon,Koo Kyung-Hoi
The Journal of bone and joint surgery. American volume
BACKGROUND:The hypothesis that the combined necrotic angle measurement from magnetic resonance imaging scans predicts the subsequent risk of collapse in hips with femoral head necrosis was tested. METHODS:Thirty-seven hips with early stage osteonecrosis in thirty-three consecutive patients were investigated. With use of the modified method of Kerboul et al., we measured the arc of the femoral surface involved by necrosis on a midcoronal as well as a midsagittal magnetic resonance image (rather than an anteroposterior and a lateral radiograph) and then calculated the sum of the angles. On the basis of the magnitude of the resulting combined angle, hips were classified into four categories: grade 1 (<200 degrees), grade 2 (200 degrees to 249 degrees), grade 3 (250 degrees to 299 degrees), and grade 4 (>/=300 degrees). After the initial evaluations, the hips were randomly assigned to a core decompression group or a nonoperative group. Patients underwent regular follow-up until femoral head collapse or for a minimum of five years. RESULTS:Seven grade-4 hips and sixteen grade-3 hips had development of femoral head collapse by thirty-six months. Six of the nine grade-2 hips and none of the five grade-1 hips collapsed (log-rank test, p < 0.01). None of the four hips with a combined necrotic angle of </=190 degrees (the low-risk group) collapsed, all twenty-five hips with a combined necrotic angle of >/=240 degrees (the high-risk group) collapsed, and four (50%) of the eight hips with a combined necrotic angle between 190 degrees and 240 degrees (the moderate-risk group) collapsed during the study period. CONCLUSIONS:The Kerboul combined necrotic angle, as ascertained with use of magnetic resonance imaging scans instead of radiographs, is a good method to assess future collapse in hips with femoral head osteonecrosis. LEVEL OF EVIDENCE:Prognostic Level I. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.
10.2106/JBJS.F.00535
Quantitative MRI Helps to Detect Hip Ischemia: Preclinical Model of Legg-Calvé-Perthes Disease.
Radiology
Purpose To determine whether quantitative MRI relaxation time mapping techniques can help to detect ischemic injury to the developing femoral head. Materials and Methods For this prospective animal study conducted from November 2015 to February 2018, 10 male 6-week-old piglets underwent an operation to induce complete right femoral head ischemia. Animals were humanely killed at 48 hours (n = 2) or 4 weeks (n = 8) after the operation, and the operated and contralateral-control femoral heads were harvested and frozen. Thawed specimens were imaged at 9.4-T MRI by using T1, T2, T1 in the rotating frame (T1ρ), adiabatic T1ρ, relaxation along a fictitious field (RAFF), and T2* mapping and evaluated with histologic analysis. Paired relaxation time differences between the operated and control femoral heads were measured in the secondary ossification center (SOC), epiphyseal cartilage, articular cartilage, and metaphysis and were analyzed by using a paired t test. Results In the SOC, T1ρ and RAFF had the greatest percent increases in the operated versus control femoral heads at both 48 hours (112% and 72%, respectively) and 4 weeks (74% and 70%, respectively). In the epiphyseal and articular cartilage, T2, T1ρ, and RAFF were similarly increased at both points (range, 24%-49%). At 4 weeks, T2, T1ρ, adiabatic T1ρ, and RAFF were increased in the SOC (P = .004, .018, < .001, and .001, respectively), epiphyseal cartilage (P = .009, .008, .011, and .007, respectively), and articular cartilage (P = .005, .016, .033, and .018, respectively). Histologic assessment identified necrosis in SOC and deep layer of the epiphyseal cartilage at both points. Conclusion T2, T1 in the rotating frame, adiabatic T1 in the rotating frame, and relaxation along a fictitious field maps are sensitive in helping to detect ischemic injury to the developing femoral head. © RSNA, 2018 Online supplemental material is available for this article.
10.1148/radiol.2018180497
The diagnostic value of magnetic resonance imaging in non-traumatic osteonecrosis of the femoral head.
Hauzeur J P,Pasteels J L,Schoutens A,Hinsenkamp M,Appelboom T,Chochrad I,Perlmutter N
The Journal of bone and joint surgery. American volume
To assess the effectiveness of nuclear magnetic-resonance imaging in the detection of osteonecrosis of the femoral head, we studied the cases of twenty-five patients (forty-nine hips) in whom necrosis of the femoral head was suspected on the basis of plain radiographs, computed tomographic scans, radionuclide bone scans, and magnetic resonance-imaging scans. The results of these investigations were compared, for all except one patient, with the pathological findings of transtrochanteric core biopsies of the femoral head and neck of both hips. Of the forty-nine hips, thirty-three had histological proof of osteonecrosis. Twenty-two (67 per cent) of these hips showed definite necrosis on the plain radiographs; eighteen (62 per cent), on the twenty-nine available computed tomographic scans; twenty-four (77 per cent), on the thirty-one available radionuclide bone scans; and all of the hips, on the magnetic resonance-imaging studies. In six additional hips, there were histological changes (marrow necrosis, edema, hemorrhage, and fibrosis) in the medullary spaces without detectable osteonecrosis. The plain radiographs and computed tomographic scans of these six hips were normal except for the computed tomographic scan of one, and the radionuclide uptake on bone-scanning was abnormal in four of the six, as were the magnetic resonance-imaging studies. In the two hips that had normal magnetic resonance-imaging studies, the biopsies showed only destruction of fat cells in the medullary spaces, with no edema or fibroblastic reaction.(ABSTRACT TRUNCATED AT 250 WORDS)
Observational studies on ultrasound screening for developmental dysplasia of the hip in newborns - a systematic review.
Puhan M A,Woolacott N,Kleijnen J,Steurer J
Ultraschall in der Medizin (Stuttgart, Germany : 1980)
AIM:To assess whether observational studies provide evidence to support general ultrasound screening for developmental dysplasia of the hip (DDH). METHOD:Systematic Review. Following a predefined study protocol, observational studies on ultrasound screening in unselected newborns were identified by search through 23 electronic databases and by hand search. Two reviewers selected the studies independently of each other and extracted the data. RESULTS:49 observational studies were included. The prevalence of DDH ranged from 0.5 % to 30 % depending largely on the various possible definitions of DDH. Less than 0.1 % of patients with DDH were missed by ultrasound regardless of the technique employed (Graf or Terjesen). About 90 % of newborns with Graf type IIa hips requiring ultrasound control did not develop DDH. Only six studies with 23 108 newborns reported on complications, and there was only one infant with an avascular necrosis of the femoral head. The effectiveness of a general ultrasound screening cannot be evaluated reliably for several reasons: reports were often incomplete, follow-up of newborns with normal findings at the time of screening was often not carried out, clinically meaningful data about outcome as well as control groups were missing. CONCLUSION:General ultrasound screening for developmental dysplasia of the hip cannot be sufficiently assessed by the observational studies available. The lack of evidence does not mean that ultrasound screening is ineffective, but randomized controlled trials comparing the effectiveness of different screening regimens are needed.
10.1055/s-2003-45213
Femoral head osteonecrosis: detection and grading by using a rapid MR imaging protocol.
Khanna A J,Yoon T R,Mont M A,Hungerford D S,Bluemke D A
Radiology
PURPOSE:To design and evaluate a limited magnetic resonance (MR) imaging examination that can be performed rapidly and potentially inexpensively in patients with clinical suspicion of osteonecrosis. MATERIALS AND METHODS:Both a limited and a full hip MR examination were performed prospectively in 179 hips in 92 patients with clinical suspicion of femoral head osteonecrosis. The presence of osteonecrosis was determined by two radiologists. The percentage of involvement of the femoral head weight-bearing surface was evaluated subsequently for osteonecrosis-positive hips on both sets of images. RESULTS:Both examinations were performed successfully in all cases. Agreement between the limited and full examinations for presence of osteonecrosis was 98.9% (177 of 179 cases; kappa, 0.97). Forty-six (92%) of 50 patients with femoral head osteonecrosis at both examinations were placed in the appropriate quartile of percentage of femoral head weight-bearing surface involvement by both readers (weighted kappa, 0.94). Incidental findings were made at the full examination that could not be made or were difficult to make at the limited examination. CONCLUSION:There was excellent agreement between the full and screening MR examinations for both detection of and determining the extent of osteonecrosis. The time and potential cost reduction achieved with a limited examination may allow introduction of MR imaging earlier in the diagnosis of femoral head osteonecrosis, as well as its more widespread use in patient care.
10.1148/radiology.217.1.r00oc26188
Evaluation of femoral head vascularization in slipped capital femoral epiphysis before and after cannulated screw fixation with use of contrast-enhanced MRI: initial results.
Staatz G,Honnef D,Kochs A,Hohl C,Schmidt T,Röhrig H,Günther R W
European radiology
In this study we used contrast-enhanced magnetic resonance imaging (MRI) to evaluate the vascularization of the femoral head in children with slipped capital femoral epiphysis (SCFE) before and after cannulated screw fixation. Eleven consecutive children with SCFE, seven boys and four girls, aged 10-15 years were included in the study. There were no preslips; four children had acute, three acute-on-chronic, and four chronic SCFE. The MRI examinations were performed in a 1.5 Tesla MR scanner with use of a coronal STIR sequence, a coronal contrast-enhanced T1-weighted spin-echo sequence, and a sagittal three-dimensional gradient-echo sequence. Morphology, signal intensities, and contrast-enhancement of the femoral head were assessed by two radiologists in consensus. Morphologic distortion of the physis, bone marrow edema within the metaphysis and epiphysis, and joint effusion were the preoperative MRI findings of SCFE in each child. In nine children, the vascularization of the femoral head before and after surgery was normal. In one child, a preoperative avascular zone in the superolateral aspect of the epiphysis revascularized completely after surgery. One child with severe SCFE developed avascular necrosis of the femoral head after open reduction of the slip. We conclude that MRI allows for accurate evaluation of the femoral head vascularization before and after surgery in children with SCFE.
10.1007/s00330-006-0261-y
Spontaneous resolution of osteonecrosis of the femoral head.
Cheng Edward Y,Thongtrangan Issada,Laorr Alan,Saleh Khaled J
The Journal of bone and joint surgery. American volume
BACKGROUND:The decision to proceed with surgical treatment of asymptomatic osteonecrosis of the femoral head is controversial. The purpose of the present study was to determine (1) if spontaneous resolution of osteonecrosis of the femoral head occurs, (2) how long it takes for resolution to occur, and (3) if there are predictors of spontaneous resolution. METHODS:Patients with asymptomatic osteonecrosis of the femoral head were identified from two National Institutes of Health-funded screening studies: a prospective screening study for osteonecrosis of the femoral head after organ transplantation and a study in which patients who had had surgical treatment of symptomatic osteonecrosis of the femoral head were screened for osteonecrosis of the contralateral, asymptomatic hip. The cohort of patients with asymptomatic osteonecrosis of the femoral head was then analyzed. RESULTS:Thirteen asymptomatic hips in ten patients were identified in the prospective screening study for osteonecrosis after organ transplantation, and seventeen hips in seventeen patients were identified in the contralateral hip-screening study. Three hips, all from the group of patients who had had organ transplantation, had Association Research Circulation Osseous stage-I disease with spontaneous resolution occurring later as evidenced by serial magnetic resonance imaging scans. In these three hips, the modified index of necrotic extent measured 11.10, 12.72, and 20.83, with the estimated percentage of femoral head involvement being 15% to 30% in two of the hips and <15% in the third. Resolution on magnetic resonance imaging was complete in two of the three hips and was nearly complete in the third. Resolution was not observed when the contralateral hip had symptomatic disease. CONCLUSIONS:Spontaneous resolution of osteonecrosis of the femoral head can occur. The factors that appear to be related to resolution are early, asymptomatic disease (Association Research Circulation Osseous stage I) and small lesion size (a modified index of necrotic extent of <25). A larger series is necessary before these factors can be verified as being independent predictors of resolution. Initial signs of resolution may take as long as one year to occur. LEVEL OF EVIDENCE:Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.
10.2106/00004623-200412000-00002
Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation.
Beltran J,Herman L J,Burk J M,Zuelzer W A,Clark R N,Lucas J G,Weiss L D,Yang A
Radiology
A retrospective evaluation of magnetic resonance (MR) imaging for the detection of avascular necrosis (AVN) of the femoral head was performed in 49 patients (85 hips) with clinical suspicion of AVN. Positive findings at bone biopsy or evidence on plain radiographs was considered proof of AVN. Absence of clinical symptoms and of radiographic findings for a minimum of 18 months after MR imaging was considered evidence of the absence of AVN. All patients were studied with plain radiography and technetium-99m methylene diphosphonate bone scintigraphy. Five hips had negative MR images, positive findings at bone marrow biopsy, positive bone pressure measurement (BMP), and positive bone scans. A comparison between MR images and bone scans showed MR imaging to be superior, with a sensitivity of 88.8% (vs. 77.5%) and a specificity of 100% (vs. 75%). BMP was the most sensitive (92%) but least specific test (57%).
10.1148/radiology.166.1.3336682
Prediction of collapse with magnetic resonance imaging of avascular necrosis of the femoral head.
Shimizu K,Moriya H,Akita T,Sakamoto M,Suguro T
The Journal of bone and joint surgery. American volume
In order to predict the probability of collapse of a femoral head in which there is avascular necrosis, we used magnetic resonance imaging to evaluate sixty-six hips (fifty patients) in which avascular necrosis was in the early stages and in which collapse of the head was not yet visible. The hips were followed radiographically for an average of forty-nine months (range, sixteen to eighty-four months), and with magnetic resonance imaging for an average of forty-four months (range, twelve to seventy-three months). Twenty-one (32 per cent) of the femoral heads had collapsed by thirty-two months. Of the twenty-three femoral heads in which necrosis involved at least one-fourth of the diameter of the head and encompassed at least two-thirds of the major weight-bearing area, seventeen (74 per cent) had collapsed by thirty-two months.
10.2106/00004623-199402000-00007
MRI-guidance in percutaneous core decompression of osteonecrosis of the femoral head.
Kerimaa Pekka,Väänänen Matti,Ojala Risto,Hyvönen Pekka,Lehenkari Petri,Tervonen Osmo,Blanco Sequeiros Roberto
European radiology
OBJECTIVES:The purpose of this study was to evaluate the usefulness of MRI-guidance for core decompression of avascular necrosis of the femoral head. MATERIALS AND METHODS:Twelve MRI-guided core decompressions were performed on patients with different stages of avascular necrosis of the femoral head. The patients were asked to evaluate their pain and their ability to function before and after the procedure and imaging findings were reviewed respectively. RESULTS:Technical success in reaching the target was 100 % without complications. Mean duration of the procedure itself was 54 min. All patients with ARCO stage 1 osteonecrosis experienced clinical benefit and pathological MRI findings were seen to diminish. Patients with more advanced disease gained less, if any, benefit and total hip arthroplasty was eventually performed on four patients. CONCLUSIONS:MRI-guidance seems technically feasible, accurate and safe for core decompression of avascular necrosis of the femoral head. Patients with early stage osteonecrosis may benefit from the procedure. KEY POINTS:• MRI is a useful guidance method for minimally invasive musculoskeletal interventions. • Bone drilling seems beneficial at early stages of avascular necrosis. • MRI-guidance is safe and accurate for bone drilling.
10.1007/s00330-015-3905-y
Correlation of the findings of magnetic resonance imaging with those of bone biopsy in patients who have stage-I or II ischemic necrosis of the femoral head.
Seiler J G,Christie M J,Homra L
The Journal of bone and joint surgery. American volume
A prospective study was undertaken to determine the diagnostic accuracy of magnetic resonance imaging in the evaluation of a symptomatic hip for which a diagnosis of early ischemic necrosis of the femoral head was suspected. Fifteen patients (sixteen symptomatic hips), for whom the findings of magnetic resonance imaging were consistent with a diagnosis of osteonecrosis of the femoral head, had a core decompression and a biopsy of the contents of the core. Preoperative magnetic-resonance imaging was useful for planning which segment of the femoral head should be biopsied. Plain radiographs and tomograms of the hips were also made. On the basis of the plain radiographs, ten hips were determined to have Stage-I findings and six hips, Stage-II ischemic necrosis, according to the system of Ficat and of Arlet and Ficat. Histological study revealed evidence of necrosis in all of the biopsy specimens of bone. We concluded that findings of magnetic resonance imaging that are characteristic of osteonecrosis correlate well with the results of biopsies of bone in patients who have an early stage of ischemic necrosis. Magnetic resonance imaging is a highly sensitive and specific method for both the diagnosis and the location of Stage-I and Stage-II osteonecrosis.
Bone marrow oedema on MR imaging indicates ARCO stage 3 disease in patients with AVN of the femoral head.
Meier Reinhard,Kraus Tobias M,Schaeffeler Christoph,Torka Sebastian,Schlitter Anna Melissa,Specht Katja,Haller Bernhard,Waldt Simone,Rechl Hans,Rummeny Ernst J,Woertler Klaus
European radiology
OBJECTIVES:To test the hypothesis that bone marrow oedema (BME) observed on MRI in patients with avascular necrosis (AVN) of the femoral head represents an indicator of subchondral fracture. METHODS:Thirty-seven symptomatic hips of 27 consecutive patients (53% women, mean age 49.2) with AVN of the femoral head and associated BME on magnetic resonance (MR) imaging were included. MR findings were correlated with computed tomography (CT) of the hip and confirmed by histopathological examination of the resected femoral head. Imaging studies were analysed by two radiologists with use of the ARCO classification. RESULTS:On MR imaging a fracture line could be identified in 19/37 (51%) cases, which were classified as ARCO stage 3 (n = 15) and stage 4 (n = 4). The remaining 18/37 (49%) cases were classified as ARCO stage 2. However, in all 37/37 (100%) cases a subchondral fracture was identified on CT, indicating ARCO stage 3/4 disease. The extent of subchondral fractures and the femoral head collapse was graded higher on CT as compared to MRI (P < 0.05). Histopathological analysis confirmed bone necrosis and subchondral fractures. CONCLUSIONS:In patients with AVN, BME of the femoral head represents a secondary sign of subchondral fracture and thus indicates ARCO stage 3 disease. KEY POINTS:BME on MRI in AVN of femoral head indicates a subchondral fracture. BME in AVN of the femoral head represents ARCO stage 3/4 disease. CT identifies subchondral fractures and femoral head collapse better than MR imaging. This knowledge helps to avoid understaging and to trigger adequate treatment.
10.1007/s00330-014-3216-8
Evaluation of magnetic resonance imaging in the diagnosis of osteonecrosis of the femoral head. Accuracy compared with radiographs, core biopsy, and intraosseous pressure measurements.
Robinson H J,Hartleben P D,Lund G,Schreiman J
The Journal of bone and joint surgery. American volume
The accuracy of magnetic resonance imaging in the detection of osteonecrosis of the femoral head was compared with that of other diagnostic methods in current use: plain radiography, bone-marrow pressure determinations, intramedullary venography, and histological examination of core-biopsy bone specimens. In the first phase of the study, forty-eight patients (ninety-six hips) who were at high risk for avascular necrosis were studied. Abnormal patterns on magnetic resonance imaging, consistent with those seen in necrosis, were found in all hips that were suspected of having Ficat Stage-2 or 3 changes on the basis of radiographic evidence of the disease. Abnormal patterns on magnetic resonance imaging that were characteristic of avascular necrosis were also observed in 17 per cent of the hips that were suspected of having Ficat Stage-0 changes and in 64 per cent of those that showed Stage-1 changes, all with no radiographic changes. In the second phase of the study, twenty-three of the ninety-six hips that were suspected of having early-stage necrosis of the femoral head but showed slight or no radiographic changes were studied by repeat radiographs, Ficat functional evaluations of bone, core biopsies of the femoral head, and magnetic resonance imaging. Of the twenty-three hips, eighteen (78 per cent) had positive changes on magnetic resonance imaging; nineteen (83 per cent) had positive histological evidence of necrosis; and fourteen (61 per cent) had positive findings by bone-marrow pressure studies and intramedullary venography. Although false-negative and false-positive results were observed with magnetic resonance imaging, the over-all results of this study suggest that magnetic resonance imaging may be useful for the early diagnosis of avascular necrosis.
Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.
Mitchell D G,Rao V M,Dalinka M K,Spritzer C E,Alavi A,Steinberg M E,Fallon M,Kressel H Y
Radiology
To better correlate the appearance of avascular necrosis (AVN) of the femoral head on magnetic resonance (MR) images with the stage of disease, MR images of 56 proved AVN lesions were compared with staging from corresponding radiographs (n = 56), Tc-99m scans (n = 41), and grade of symptoms (n = 28). Fractures complicating AVN were seen in 28 (50%) of 56 radiographs (radiographic stages III-V). With long repetition (TR) and echo delay (TE) times, a characteristic "double line sign" consisting of high signal intensity inside a low-intensity peripheral rim was seen in 45 lesions (80%). The central region within the rim was isointense with marrow fat on both short and long TR and TE images in 20 (71%) of 28 lesions uncomplicated by fracture (stages I-II) but in only four (14%) of 28 stage III-V lesions (P less than .001). Symptoms were least severe in lesions isointense with fat and most severe in lesions with low-signal central regions at short and long TRs and TEs. The peripheral double line sign on long TR/TE images may add specificity to the diagnosis of AVN by MR imaging. A chronologic pattern of central MR signal features is presented which may allow staging of AVN by MR imaging.
10.1148/radiology.162.3.3809484
Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version).
Journal of orthopaedic translation
Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies. TRANSLATIONAL POTENTIAL OF THIS ARTICLE:New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.
10.1016/j.jot.2019.12.004
Femoral head perfusion and composition: MR imaging and spectroscopic evaluation of patients with systemic lupus erythematosus and at risk for avascular necrosis.
Bluemke D A,Petri M,Zerhouni E A
Radiology
PURPOSE:To measure fat content and relative marrow perfusion of the femoral head in patients at risk for avascular necrosis. MATERIALS AND METHODS:Thirteen patients with systemic lupus erythematosus (SLE) without avascular necrosis and with long-term corticosteroid treatment and 12 healthy subjects were evaluated. Hip perfusion was assessed with gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging. Marrow composition in the femoral head and neck was measured with hydrogen-1 MR spectroscopy. RESULTS:Percentage fat content in the femoral head was similar between the two groups (SLE patients, 77% +/- 5 [standard deviation]; healthy subjects, 78% +/- 6; P = .74). Rate of enhancement of the femoral head was significantly higher in the SLE than the healthy group (11%/min +/- 6 vs 6.9%/min +/- 3, respectively; P = .05), was inversely related to fat content in healthy subjects (r = -.74, P = .02), and was more variable in the SLE group (r = -.53, P = .11). CONCLUSION:Perfusion of the femoral head is inversely related to marrow fat content in healthy and is higher in SLE patients without hip avascular necrosis.
10.1148/radiology.197.2.7480688
Femoral head deformation and repair following induction of ischemic necrosis: a histologic and magnetic resonance imaging study in the piglet.
Shapiro Frederic,Connolly Susan,Zurakowski David,Menezes Nina,Olear Elizabeth,Jimenez Mauricio,Flynn Evelyn,Jaramillo Diego
The Journal of bone and joint surgery. American volume
BACKGROUND:Ischemic necrosis of the femoral head can be induced surgically in the piglet. We used this model to assess femoral head deformation and repair in vivo by sequential magnetic resonance imaging and by correlating end-stage findings with histologic assessments. METHODS:Ischemic necrosis of the femoral head was induced in ten three-week-old piglets by tying a silk ligature around the base of the femoral neck (intracapsular) and cutting the ligamentum teres. We used magnetic resonance imaging with the piglets under general anesthesia to study the hips at forty-eight hours and at one, two, four, and eight weeks. Measurements on magnetic resonance images in the midcoronal plane of the involved and control sides at each time documented the femoral head height, femoral head width, superior surface cartilage height, and femoral neck-shaft angle. Histologic assessments were done at the time of killing. RESULTS:Complete ischemia of the femoral head was identified in all involved femora by magnetic resonance imaging at forty-eight hours. Revascularization began at the periphery of the femoral head as early as one week and was underway in all by two weeks. At eight weeks, magnetic resonance imaging and histologic analysis showed deformation of the femoral head and variable tissue deposition. Tissue responses included (1) vascularized fibroblastic ingrowth with tissue resorption and cartilage, intramembranous bone, and mixed fibro-osseous or fibro-cartilaginous tissue synthesis and (2) resumption of endochondral bone growth. At eight weeks, the mean femoral head measurements (and standard error of the mean) for the control compared with the ligated femora were 10.4 +/- 0.4 and 4.8 +/- 0.4 mm, respectively, for height; 26.7 +/- 0.8 and 31.2 +/- 0.8 mm for diameter; 1.1 +/- 0.1 and 2.3 +/- 0.1 mm for cartilage thickness; and 151 degrees +/- 2 degrees and 135 degrees +/- 2 degrees for the femoral neck-shaft angle. Repeated-measures mixed-model analysis of variance revealed highly significant effects of ligation in each parameter (p < 0.0001). CONCLUSIONS:Magnetic resonance imaging allows for the assessment of individual hips at sequential time periods to follow deformation and repair. There was a variable tissue response, and histologic assessment at the time of killing was shown to correlate with the evolving and varying magnetic resonance imaging signal intensities. Femoral head height on the ischemic side from one week onward was always less than the initial control value and continually decreased with time, indicating collapse as well as slowed growth. Increased femoral head width occurred relatively late (four to eight weeks), indicating cartilage model overgrowth concentrated at the periphery.
10.2106/JBJS.H.01464
Deep Learning-Based End-to-End Diagnosis System for Avascular Necrosis of Femoral Head.
Li Yang,Li Yan,Tian Hua
IEEE journal of biomedical and health informatics
As the first diagnostic imaging modality of avascular necrosis of the femoral head (AVNFH), accurately staging AVNFH from a plain radiograph is critical yet challenging for orthopedists. Thus, we propose a deep learning-based AVNFH diagnosis system (AVN-net). The proposed AVN-net reads plain radiographs of the pelvis, conducts diagnosis, and visualizes results automatically. Deep convolutional neural networks are trained to provide an end-to-end diagnosis solution, covering tasks of femoral head detection, exam-view identification, side classification, AVNFH diagnosis, and key clinical notes generation. AVN-net is able to obtain state-of-the-art testing AUC of 0.97 ( 95% CI: 0.97-0.98) in AVNFH detection and significantly greater F1 scores than less-to-moderately experienced orthopedists in all diagnostic tests ( p < 0.01). Furthermore, two real-world pilot studies were conducted for diagnosis support and education assistance, respectively, to assess the utility of AVN-net. The experimental results are promising. With the AVN-net diagnosis as a reference, the diagnostic accuracy and consistency of all orthopedists considerably improved while requiring only 1/4 of the time. Students self-studying the AVNFH diagnosis using AVN-net can learn better and faster than the control group. To the best of our knowledge, this study is the first research on the prospective use of a deep learning-based diagnosis system for AVNFH by conducting two pilot studies representing real-world application scenarios. We have demonstrated that the proposed AVN-net achieves expert-level AVNFH diagnosis performance, provides efficient support in clinical decision-making, and effectively passes clinical experience to students.
10.1109/JBHI.2020.3037079
Magnetic resonance image diagnosis of femoral head necrosis based on ResNet18 network.
Liu Yan,She Guo-Rong,Chen Shu-Xaing
Computer methods and programs in biomedicine
PURPOSE:In order to enhance the practicability of the application of Magnetic Resonance Imaging (MRI) in the diagnosis of femoral head necrosis, combined with the convolutional neural network (CNN), we propose an automatic identification of femoral head necrosis model based on the ResNet18 network. METHODS:In order to verify that MRI has a higher detection rate for early femoral head necrosis, we collected 360 cases of femoral MRI and the same number of femoral CT. Combining this method with ResNet18, AlexNet, and VGG16, compare the clinical staging and typical signs of femoral head necrosis with 8 diagnostic methods. RESULTS:The total detection rate of MRI combined with ResNet18 is as high as 99.27%, which is much higher than the other three comparison methods. The sensitivity is 97%, the specificity is 98.99%, and the accuracy is 98.23%. The difference is statistically significant. CONCLUSION:The automatic recognition femoral MRI model based on the ResNet18 network has a high detection rate for early femoral head necrosis, and can effectively detect bone marrow edema, line-like signs and other signs, providing a reliable reference for early treatment.
10.1016/j.cmpb.2021.106254
Avascular necrosis of the proximal femur in developmental dislocation of the hip. Incidence, risk factors, sequelae and MR imaging for diagnosis and prognosis.
Kruczynski J
Acta orthopaedica Scandinavica. Supplementum
Avascular necrosis of the proximal femur still remains the major complication of the treatment for developmental dislocation of the hip. In a three part study I reviewed this problem. Part I analyzed incidence, causes, and risk factors of avascular necrosis. In 105 children with 113 hips who developed avascular necrosis out of 636 consecutive patients with 823 hips treated nonoperatively for developmental dislocation of the hip in the years 1972-1976 the risk factors of avascular necrosis were determined. A method of treatment in most cases was Frejka pillow. Conventional radiographs obtained in AP views during the course of treatment and follow-up were analyzed. Avascular necrosis was found in 14 percent of the hips, classified as mild (49%), moderate (14%), and severe (37%). The differences between mild and severe cases were significant as regards age at the onset of treatment (p 0.006); with higher average age in mild forms, and degree of dislocation (p 0.01) with higher values in severe forms. The older the child was at the onset of treatment, the greater the risk of necrosis, notably if treatment was begun after 6 months of age. However, the incidence of the more severe cases was higher in the group up to 6 month of age. In general, avascular necrosis was more likely to occur in cases with high degree of initial dislocation and the differences between groups with low and high degree of dislocation were significant. In the group with highest initial dislocation the number of both mild and severe forms was high. Part II evaluated the growth and remodeling of the hip joint with avascular necrosis after nonoperative treatment of developmental dislocation on the basis of conventional radiography. An attempt was also made to determine the correlation between the severity of necrosis as seen in conventional radiography and the clinical and radiographic appearance of the hip after completion of growth. Finally the prognostic value of conventional radiography in prediction of deformities of the proximal femur due to necrosis was estimated. 68 patients with 98 involved hips treated exclusively nonoperatively for developmental dislocation of the hip in whom avascular necrosis developed were selected for the study. The average age at the time when the final radiograph was made was 25 (18-36) years and the average follow-up period was 23 (18-35) years. 16 patients (27 hips) were examined twice after completion of growth with the time interval of 10 years, the second examination being at an average age of 30 (26-36) years. In this group also progress of signs and symptoms of degenerative changes in clinical and radiographic examination was noted. To achieve sufficient data necessary to establish indications for further operative treatment in 2 patients also CT examinations with three-dimensional surface reconstruction were performed after physeal closure. Physical examinations were performed in all patients after completion of growth. Radiographs made before the onset of treatment for developmental dislocation of the hip, during treatment, at the child's age of 4-6 years, all obtained until the cessation of growth, and at final assessment, were studied. By physical evaluation 77 hips were rated as excellent or good, being pain free or with only occasional mild pain after walking long distances, with a good range of hip motion and negative Trendelenburg sign. The reasons for 21 fair or poor clinical end-results were pain, mostly with activity, and limp due to pain and abductor weakness. By radiographic evaluation in this group there were 50 hips rated as excellent or good, and 48 hips rated as fair or poor. In 29 hips excellent or good clinical findings at final review contrasted with fair or poor radiographic scores. In no case fair or poor clinical end-result coexisted with excellent radiographic ones. In the group examined twice after completion of growth with the time interval of 10 years no difference in clinical score was found in
Whole-joint magnetic resonance imaging to assess osteonecrosis in pediatric patients with acute lymphoblastic lymphoma.
Inaba Hiroto,Varechtchouk Olga,Neel Michael D,Ehrhardt Matthew J,Metzger Monika L,Karol Seth E,Ness Kirsten K,Ribeiro Raul C,Pui Ching-Hon,Relling Mary V,Sandlund John T,Kaste Sue C
Pediatric blood & cancer
BACKGROUND:Osteonecrosis is a debilitating complication in children and adolescents with acute lymphoblastic leukemia or acute lymphoblastic lymphoma (LLy). An objective screening test to identify patients at risk for symptomatic, extensive joint involvement will help manage osteonecrosis. METHODS:We performed a prospective, longitudinal pilot study with whole-joint magnetic resonance imaging (MRI) of shoulders, elbows, hips, knees, ankles, and hindfeet to evaluate the incidence and timing of osteonecrosis involving multiple joints in 15 patients with LLy aged 9-21 years at diagnosis. RESULTS:Osteonecrosis affecting ≥30% of the epiphysis occurred in eight of 15 patients, with a high prevalence in hips (12 of 26 examined [46%]) and knees (10 of 26 [38%]) post reinduction I and in shoulders (seven of 20 [35%]) post reinduction II. Most osteonecrotic hips and knees with ≥30% epiphyseal involvement became symptomatic and/or underwent surgery (100% and 82%, respectively). All eight patients with ≥30% epiphyseal involvement had multijoint involvement. Seven of these patients had hip or knee osteonecrosis by the end of remission induction, and only these patients developed osteonecrosis that became symptomatic and/or underwent surgery in their hips, knees, shoulders, ankles, and/or feet; all of these joints were associated with epiphyseal abnormalities on post reinduction I imaging. CONCLUSIONS:MRI screening in adolescent patients with LLy revealed osteonecrosis in multiple joints. Initial screening with hip and knee MRI at the end of induction may identify susceptible patients who could benefit from referrals to subspecialties, more extensive follow-up imaging of other joints, and early medical and surgical interventions.
10.1002/pbc.28336
Unique MRI findings as an early predictor of osteonecrosis in pediatric acute lymphoblastic leukemia.
Sansgiri Rakhee Kisan,Neel Michael D,Soto-Fourier Manuel,Kaste Sue C
AJR. American journal of roentgenology
OBJECTIVE:Osteonecrosis is a potential complication of glucocorticoid chemotherapy in children surviving leukemia. Early diagnosis may allow effective interventions to minimize or ameliorate joint deterioration and obviate surgical intervention. We investigated the significance of MRI signal changes that precede the currently recognized "double-line" changes, which are considered pathognomic of osteonecrosis. MATERIALS AND METHODS:We retrospectively reviewed MRI scans acquired during prospective screening and follow-up of pediatric patients with leukemia for osteonecrosis. RESULTS:Of 481 patients, we identified 21 cases (4.3%; 12 boys; median age at leukemia diagnosis, 12.8 years) with subtle poorly defined geographically delineated MRI signal abnormalities in knees or hips, or both, that progressed over a median of 4 months (range, 1.6-18.5 months) to florid MRI signs of osteonecrosis. Articular surface collapse developed in three hips (two patients) and three knees (three patients). Three patients subsequently underwent surgical intervention (one bilateral total hip arthroplasty and one bilateral and one unilateral hip core decompression). The median duration of follow-up was 27 months (range, 1.9-90.7 months). CONCLUSION:The MRI signal abnormalities described here appear to herald extensive osteonecrosis and precede the typical MRI findings of osteonecrosis previously reported in the literature.
10.2214/AJR.11.7367
Chemical-shift-selective magnetic-resonance imaging of avascular necrosis of the femoral head.
Matthaei D,Frahm J,Haase A,Schuster R,Bomsdorf H
Lancet (London, England)
Chemical-shift-selective (CHESS) nuclear-magnetic-resonance (NMR) imaging is a new method for separating "water" and "fat" (CH2) resonances in proton NMR imaging. Its major advantage over conventional composite NMR imaging is the contrast enhancement, which in particular allows the detection of small water-containing structures, such as vessels or joint surfaces, normally obscured by fat signals. First clinical findings in the femoral head with avascular necrosis are reported.
10.1016/s0140-6736(85)91388-1
Bone scintigraphy for osteonecrosis of the knee in patients with non-traumatic osteonecrosis of the femoral head: comparison with magnetic resonance imaging.
Sakai T,Sugano N,Nishii T,Haraguchi K,Yoshikawa H,Ohzono K
Annals of the rheumatic diseases
OBJECTIVE:To determine whether technetium bone scintigraphy (BS) is useful for screening of non-traumatic osteonecrosis of the knee (ONK), which was a major affected site, secondary to the femoral head, among multiple osteonecrosis, in patients with non-traumatic osteonecrosis of the femoral head (ONFH). METHODS:A total of 214 knee joints in 107 patients with ONFH were evaluated by BS and a comparison made with magnetic resonance imaging (MRI). ONK was classified into five sites, including the femoral condyles (ONFC), distal femoral metaphysis (ONFM), tibial plateau (ONTP), proximal tibial metaphysis (ONTM), and patella (ONP). RESULTS:Based on the diagnosis by MRI, ONK was detected in 103 knees of 62 patients (48%). ONFC was most common (86 knees, 40%), ONFM (15%), followed by ONTM (10%), ONP (3%), and ONTP (0.9%). Sensitivity, specificity, and accuracy of BS for ONFC detection were 63%, 71%, and 68%, respectively. When the ONFC lesions on the coronal views of MRI were large or medium sized and occupied two thirds, or the entire anteroposterior joint surface on the sagittal views, the sensitivity of BS for ONFC detection increased to 89% (34/38 knees). The sensitivity of BS for ONFM, ONTM, and ONP detection was 3%, 0%, and 0%, respectively, but these lesions showed a low likelihood of collapse. CONCLUSION:BS is useful for screening large ONK in patients with ONFH given that 89% of patients with ONFC who had a high risk of collapse of the knee were identified.
10.1136/ard.60.1.14
Utility of early screening magnetic resonance imaging for extensive hip osteonecrosis in pediatric patients treated with glucocorticoids.
Kaste Sue C,Pei Deqing,Cheng Cheng,Neel Michael D,Bowman W Paul,Ribeiro Raul C,Metzger Monika L,Bhojwani Deepa,Inaba Hiroto,Campbell Patrick,Rubnitz Jeffrey E,Jeha Sima,Sandlund John T,Downing James R,Relling Mary V,Pui Ching-Hon,Howard Scott C
Journal of clinical oncology : official journal of the American Society of Clinical Oncology
PURPOSE:Hip osteonecrosis frequently complicates treatment with glucocorticoids. When extensive (affecting ≥ 30% of the epiphyseal surface), 80% of joints collapse within 2 years, so interventions are needed to prevent this outcome. PATIENTS AND METHODS:This prospective cohort magnetic resonance imaging (MRI) screening study included all consecutive children treated for acute lymphoblastic leukemia on a single protocol. Hip MRI was performed at 6.5 and 9 months from diagnosis (early screening) and at completion of chemotherapy (final evaluation) to determine whether screening could identify extensive hip osteonecrosis before symptom development. RESULTS:Of 498 patients, 462 underwent screening MRI. Extensive asymptomatic osteonecrosis was identified by early screening in 26 patients (41 hips); another four patients (seven hips) were detected after the screening period, such that screening sensitivity was 84.1% and specificity was 99.4%. The number of joints screened to detect one lesion was 20.1 joints for all patients, 4.4 joints for patients older than 10 years, and 198 joints for patients ≤ 10 years old (P < .001). Of the 40 extensive lesions in patients older than 10 years, 19 required total hip arthroplasty and none improved. Of eight extensive lesions in younger patients, none required arthroplasty and four improved. CONCLUSION:In patients age 10 years old or younger who require prolonged glucocorticoid therapy, screening for extensive hip osteonecrosis is unnecessary because their risk is low and lesions tend to heal. In children older than 10 years, early screening successfully identifies extensive asymptomatic lesions in patients who would be eligible for studies of interventions to prevent or delay joint collapse.
10.1200/JCO.2014.57.5480