Surgical Treatment of Osteonecrosis of the Femoral Head Using Minimally Invasive Surgical Drilling and Cancellous Grafting at Brazzaville University Hospital

Introduction: Osteonecrosis of the femoral head (ONTF) is a debilitating condition. Several treatments have been proposed with controversial results. The aim of our study was to evaluate treatment by surgical drilling coupled with in situ cancellous grafting. Materials and methods: Our study was a case-control study conducted at Brazzaville University Hospital from 1st January 2018 to 31 December 2023. It compared two groups of patients with ONTF: non-operated (13 patients, 20 hips) and operated (22 patients, 35 hips). We used the visual digital scale (VDS) for pain assessment, the Merle D’Aubigne-Postel (MDP) scoring system for clinical and functional assessment, and the evolution of necrosis. Results: The group of non-operated patients had a mean age of 35.69 ± 3.4 years, no improvement in pain with an EVN above seven at the last recoil and a mean global MDP score falling from 12.7 before offloading to 10.13 at one year. The group of patients operated on had a mean age of 37.86 ± 7.02 years, a significant reduction in pain (p = 0.00004) and a significantly increased MDP score (p = 0.0034). A comparison of the two groups of patients showed significant stabilization of the necrotic lesions in the operated patients (p = 0.00067), with better satisfaction in the same group. Conclusion: Surgical drilling combined with grafting in the treatment of early-stage ONTF has improved progress in our series. The technique is reproducible and less invasive. It has made it possible to delay unfavorable progression and, consequently, hip replacement surgery.

Bone palsy eliminates granules to regulate Wnt/PI3K-AKT signaling pathway and intervene in hormonal osteonecrosis of the femoral head in rabbits

Objective:To investigate the therapeutic effect of osteopathic osteopathy on hormonal osteonecrosis in rabbits by regulating the Wnt/PI3K-AKT signaling pathway.Methods:Thirty clean-grade New Zealand rabbits were randomly divided into control group,model group and experimental group,and all except for the control group,allogeneic serum combined with glucocorticoids were used to establish animal models of simulated hormonal osteonecrosis of the femoral head.After successful modeling,the experimental group was given the model group and the control group the same amount of normal saline,and the experimental group was given bone palsy granule concentrate according to the equivalent dose of humans and rabbits,once a day for 8 weeks,and after intraperitoneal anesthesia,blood was collected from the extracorporeal heart and the serum ALP and TGF-β1 levels were detected by immunoenzyme-linked adsorption.The experimental animals were sacrificed,,and the bilateral femoral heads of rabbits were removed for hematoxylin-eosin staining,and the apoptosis of cells in the femoral head area was observed by TUNEL staining.RT-qPCR analyzed the expression of Bax and Bcl-2 genes,and Western blot detected the expression levels of pathway proteins Wnt,β-catenin,GSK-3β,AKT and p-AKT.Results:Compared with the control group,the expression levels of ALP and TGF-β1 in rabbit bone tissue in the model group decreased significantly(P<0.05),the bone trabeculae were sparse and thinned,the number of hollow bone fosses and the number of apoptosis-positive cells increased significantly(P<0.05),the expression of pro-apoptotic gene Bax was increased,and the expression of anti-apoptotic gene Bcl-2 was inhibited(P<0.05).After the intervention and treatment of bone palsy granules,the hollow bone depression and apoptosis of rabbit bone tissue in the experimental group were effectively improved(P<0.05).In addition,compared with the model group,the osteopathic elimination particles could upregulate the expression of ALP and TGF-β1(P<0.05),promote the expression of pathway proteins Wnt andβ-catenin,increase the phosphorylation level of AKT,and downregulate the expression of GSK-3β(P<0.05).Conclusion:Under glucocorticoids,osteoblast development dysfunction and apoptosis increase.Bone palsy granules can regulate the two signaling pathways of Wnt/PI3K-AKT,promote osteoblast development and inhibit apoptosis,effectively maintain bone metabolic balance,prolong the collapse time of the femoral head,and further treat osteonecrosis of the femoral head.

The role and research progress of PI3K/AKT signaling pathway in non-traumatic osteonecrosis of the femoral head

Non-traumatic osteonecrosis of the femoral head(NONFH)is one of the most common orthopedic diseases,influenced by multiple signaling pathways and inflammatory factors.The PI3K/AKT signaling pathway is closely related to various biological processes such as apoptosis,autophagy,and metabolism in cells.Increasing evidence suggests that it plays an important role in the development of femoral head necrosis.This paper aims to explore the mechanism of the PI3K/AKT signaling pathway in the pathogenesis of NONFH by analyzing its regulation of lipid metabolism,cell apoptosis and autophagy,and intravascular coagulation.This study provides new insights for the research of NONFH.

Effects of individual shock wave therapy vs celecoxib on hip pain caused by femoral head necrosis

BACKGROUND Celecoxib has been used to treat hip discomfort and functional difficulties associated with osteonecrosis of the femoral head(ONFH),although significant adverse reactions often follow long-term use.Extracorporeal shock wave therapy(ESWT)can delay the progression of ONFH,alleviate the pain and functional limitations it causes,and avoid the adverse effects of celecoxib.AIM To investigate the effects of individual ESWT,a treatment alternative to the use of celecoxib,in alleviating pain and dysfunction caused by ONFH.METHODS This was a randomized,controlled,double-blinded,non-inferiority trial.We examined 80 patients for eligibility in this study;8 patients were excluded based on inclusion and exclusion criteria.A total of 72 subjects with ONFH were randomly assigned to group A(n=36;celecoxib+alendronate+sham-placebo shock wave)or group B(n=36;individual focused shock wave[ESWT based on magnetic resonance imaging three-dimensional(MRI-3D)reconstruction]+alendronate).The outcomes were assessed at baseline,at the end of treatment,and at an 8-wk follow-up.The primary outcome measure was treatment efficiency after 2 wk of intervention using the Harris hip score(HHS)(improvement of 10 points or more from the baseline was deemed sufficient).Secondary outcome measures were post-treatment HHS,visual analog scale(VAS),and Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC)scores.RESULTS After treatment,the pain treatment efficiency of group B was greater than that of group A(69%vs 51%;95%CI:4.56%to 40.56%),with non-inferiority thresholds of-4.56%and-10%,respectively.Furthermore,the HHS,WOMAC,and VAS scores in group B dramatically improved during the follow-up period as compared to those in group A(P<0.001).After therapy,the VAS and WOMAC in group A were significantly improved from the 2nd to 8th wk(P<0.001),although HHS was only significantly altered at the 2 wk point(P<0.001).On the 1st d and 2nd wk after treatment,HHS and VAS scores were different between groups,with the difference in HHS lasting until week 4.Neither group had severe complications such as skin ulcer infection or lower limb motorsensory disturbance.CONCLUSION Individual shock wave therapy(ESWT)based on MRI-3D reconstruction was not inferior to celecoxib in managing hip pain and restrictions associated with ONFH.

Surface-based map plasticity of brain regions related to sensory motor and pain information processing after osteonecrosis of the femoral head

Pain is one of the manifestations of hip disorder and has been proven to lead to the remodeling of somatotopic map plasticity in the cortex.However,most studies are volume-based which may lead to inaccurate anatomical positioning of functional data.The methods that work on the cortical surface may be more sensitive than those using the full brain volume and thus be more suitable for map plasticity study.In this prospective cross-sectional study performed in Yueyang Hospital of Integrated Traditional Chinese and Western Medicine,Shanghai University of Traditional Chinese Medicine,China,20 patients with osteonecrosis of the femoral head(12 males and 8 females,aged 56.80±13.60 years)and 20 healthy controls(9 males and 11 females,aged 54.56±10.23 years)were included in this study.Data of resting-state functional magnetic resonance imaging were collected.The results revealed that compared with healthy controls,compared with the healthy controls,patients with osteonecrosis of the femoral head(ONFH)showed significantly increased surface-based regional homogeneity(Re Ho)in areas distributed mainly in the left dorsolateral prefrontal cortex,frontal eye field,right frontal eye field,and the premotor cortex and decreased surface-based Re Ho in the right primary motor cortex and primary sensory cortex.Regions showing significant differences in surfacebased Re Ho values between the healthy controls and patients with ONFH were defined as the regions of interests.Seed-based functional connectivity was performed to investigate interregional functional synchronization.When the areas with decreased surface-based Re Ho in the frontal eye field and right premotor cortex were used as the regions of interest,compared with the healthy controls,the patients with ONFH displayed increased functional connectivity in the right middle frontal cortex and right inferior parietal cortex and decreased functional connectivity in the right precentral cortex and right middle occipital cortex.Compared with healthy controls,patients with ONFH showed significantly decreased cortical thickness in the para-insular area,posterior insular area,anterior superior temporal area,frontal eye field and supplementary motor cortex and reduced volume of subcortical gray matter nuclei in the right nucleus accumbens.These findings suggest that hip disorder patients showed cortical plasticity changes,mainly in sensorimotor-and pain-related regions.This study was approved by the Medical Ethics Committee of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine,Shanghai University of Traditional Chinese Medicine(approval No.2018-041)on August 1,2018.

Protective Effect of Human Umbilical Cord Mesenchymal Stem Cells in Glucocorticoid-induced Osteonecrosis of Femoral Head

Objective:To evaluate the effect of human umbilical cord mesenchymal stem cells(hUC-MSCs)on preventing rats from glucocorticoid-induced osteonecrosis of femoral head(GC-ONFH)in the early stage in vivo and to investigate the possible mechanism of hUC-MSCs in regulating the balance of osteogenesis and adipogenesis.Methods:All rats were randomly divided into 3 groups:control group(C group),model group(M group),and intervention group(Ⅰ group).The model of GC-ONFH was developed by a sequential administration of lipopolysaccharide and methylprednisolone.The rats in the Ⅰ group were treated with caudal vein injection of hUC-MSCs.Six weeks later,the blood samples were obtained to measure the activity of alkaline phosphatase(ALP)and the content of triglyceride(TG)in serum,and the femoral heads were harvested and observed by hematoxylin-eosin staining,Micro-CT,Western blot and real-time quantitative polymerase chain reaction.Results:After intervention of hUC-MSCs,the necrosis rate of femoral head decreased from 83%(10/12)to 33%(4/12),the rate of empty bone lacuna was significantly decreased,the activity of ALP increased significantly,the content of TG decreased significantly,the bone density increased obviously,the expression of RUNX2 and Col Ⅰ increased significantly and the expression of PPARγ decreased significantly.Conclusion:These results revealed that caudal vein injection of hUC-MSCs can effectively reduce the incidence of GC-ONFH in rats by increasing ALP activity and reducing TG content in serum,increasing bone mineral density,promoting the expression of RUNX2 and Col I,and inhibiting the expression of PPARγ.

Modified technique of advanced core decompression for treatment of femoral head osteonecrosis

BACKGROUND Osteonecrosis of the femoral head(ONFH)is a destructive condition most commonly affecting young and middle-aged patients.The leading consequence of ONFH is often a significant articular disability.Effective joint-preserving surgical treatments are urgently needed for patients with early stage ONFH when outcomes of treatment are in general better than the advanced stage disease.AIM To introduce a new surgery procedure called percutaneous expanded core decompression and mixed bone graft technique,which is a new way of jointpreserving surgical treatments.METHODS The clinical data of 6 patients with ONFH diagnosed and treated with the procedure called percutaneous expanded core decompression and mixed bone graft technique at The First Hospital of Qiqihar from March 2013 to August 2019 were retrospectively analyzed;the follow-up ended in December 2019.RESULTS There were 6 male patients with an average age of 43 years in our study.Gratifying results have been obtained from the comparison of Harris hip score,visual analogue scale,and imaging examination before and after operation.CONCLUSION This new modified technique is simple,safe,and reliable.No serious perioperative complications were observed in our cases.Advantages of the single blade expandable reamer are obvious.The adjuvant substance is inexpensive and easy to obtain.Thus,this technique is an effective joint-preserving surgical treatment for patients with early stage of ONFH.

Gene testing for osteonecrosis of the femoral head in systemic lupus erythematosus using targeted next-generation sequencing:A pilot study

BACKGROUND Previous publications indicated that genetic predisposition might play important roles in the onset of osteonecrosis of the femoral head(ONFH)in systemic lupus erythematosus(SLE).Some gene loci such as complement C3d receptor 2(CR2),nitric oxide synthase 3(NOS3),collagen type II alpha 1 chain(COL2A1),protein tyrosine phosphatase non-receptor type 22(PTPN22),and transient receptor potential cation channel subfamily V member 4(TRPV4)were reported to be involved in this process.AIM To investigate whether the risk of ONFH in SLE is associated with single nucleotide variations(SNVs)in these five genes.METHODS SNVs in the CR2,NOS3,COL2A1,PTPN22,and TRPV4 genes were examined by using FastTarget and Illumina Miseq sequencing technologies in 49 cases of SLE with ONFH.Burrows–wheeler aligner was used to align the sequencing reads to hg19,and GATK and Varscan programs were used to perform SNV calling.PolyPhen-2,SIFT,and MutationTaster were used to assess the functional effects of non-synonymous SNVs.RESULTS Six of the 49 patients were confirmed to have low frequency SNVs,including one patient with SNVs in NOS3(exon 6:c.814G>A:p.E272K and exon 7:c.814G>A:p.E272K.),four in COL2A1(rs41263847:exon 29:c.1913C>T:p.T638I,exon 28:c.1706C>T:p.T569I,and rs371445823:exon 8:c.580G>A:p.A194T,exon 7:c.373G>A:p.A125T),and one in CR2(rs45573035:exon 2:c.200C>G:p.T67S).CONCLUSION The onset of ONFH in SLE might be associated with the identified SNVs in NOS3,COL2A1,and CR2.

Superior Retinacular Artery Did Not Occlude in a Rat Model of the Non-Traumatic Osteonecrosis of the Femoral Head

Non-traumatic osteonecrosis of the femoral head (ONFH) is believed to be avascular necrosis. Certainly, a disruption of a supplying artery induces necrosis in the supplying artery-dominant region. However, when an abnormality such as cell apoptosis, or another reason, is developed in the supplying artery-dominant region, it induces a disruption of the supplying artery. Therefore, to prove that ONFH is avascular necrosis, it is necessary to demonstrate the disruption of the supplying artery prior to histological osteonecrosis development. Here we investigate histologically, using a rat model, whether disruption of the supplying artery occurs before the initial development of ONFH following corticosteroid treatment. Rats were given imiquimod and methylprednisolone, and were sacrificed 1, 2, 3, 7 or 14 days after the last injection. At the sacrifice, the rat was perfused with 20 ml black Indian ink through the left ventricle. ONFH was observed in the Imiquimod + Methylprednisolone group at 7 and 14 days. The osteonecrotic area was not stained with perfused black Indian ink. However, the lateral portion of the femoral head near the superior retinacular artery was stained with the ink. In conclusion, the present study shows that the superior retinacular artery did not occlude before the initial development of ONFH histologically in rats.

Research progress of microRNA in prevention and treatment of osteonecrosis of the femoral head

In the 1980s,Feinbaum et al.first discovered miRNA in the development of worms and termed it as Lin-4.With the development of microbial science and continuous improvement in the gene sequencing technology,miRNA has been gradually gaining attention for intensive research in clinical medicine.Among these,one group of miRNAs has been confirmed to play fundamental roles in gene regulation in various orthopedics diseases,such as bone tumors,osteoarthritis,and rheumatoid arthritis.The study of miRNAs in the osteonecrosis of the femoral head(ONFH)can improve the understanding of the pathogenesis of the disease.ONFH is an orthopedic disease that is the primary cause of disrupted blood supply to the femoral head and the main symptoms of bone and muscle dysfunction.Recent studies showed that miRNA played a major role in the regulation of the microcirculation of ONFH,damage and repair of blood vessels,local microcirculation dysfunction caused by other diseases,and apoptosis of bone cells.In this study,recent related research results of miRNA and ONFH were analyzed and summarized,and the prospective in the prevention and treatment of the disease was also discussed.

Previously unexplored etiology for femoral head necrosis:Metagenomics detects no pathogens in necrotic femoral head tissue

BACKGROUND Osteonecrosis of the femoral head(ONFH)is a frequent and refractory disease whose pathogenesis has not yet been elucidated.Infection and other factors that reduce the local blood supply can lead to bone necrosis.AIM To aim of this study was to assess the relationship of ONFH with bone infection by use of metagenomic sequencing.METHODS Twelve patients with idiopathic ONFH and 12 comparable controls who were undergoing hip arthroplasty were followed up in parallel.Necrotic femoral head specimens were collected for bacterial and fungal cultures using standard methods.Bone specimens were subjected to preliminary processing,and metagenomics sequencing of microorganisms was performed.A one-way analysis of variance was used to compare bacterial species in the two groups.RESULTS Bacterial and fungal cultures exhibited no evidence of microbial growth in all isolated necrotic femoral head tissues.We thus performed metagenomic sequencing and classified the species as suspected pathogens or suspected background microorganisms based on known bacterial pathogenicity.There was no evidence of viruses,fungi,parasites,M.tuberculosis complex,or mycoplasma/chlamydia.There were also no significant differences in suspected pathogens or suspected background microorganisms(P>0.05).CONCLUSION Although we found no pathogens specific for ONFH in necrotic femoral head tissue,our research provides a foundation for future research on the metagenomics of bone pathogens.

Three-dimensional finite element analysis on the treatment of adult femoral head necrosis using different graft

Objective： To study the alternation of distribution of the stress in the necrotic femoral head with different kinds of grafting materials by using three-dimensional element methods and find out the most optimal one with sound biomechanical principles before clinical application. Methods： We prepared a three dimension finite element model of central femoral head necrosis with surface modeling technique （spiral ct）and calculated the peak stress index of necrotic portion in three situations：core drilling in 14 mm diameter and grafting with titanium, fibula, polylactide. Results： The peak stress index of normal femoral head was 0.05, but in osteonecrotic femoral head, the peak stress index was 13 times of the normal （0.67）. The value of necrotic portion with big shallow angle （0.67） was larger than the one with small deep angle （0.49）. Core drilling in 14 mm diameter and grafting with titanium, fibula and polyactide could diminish the bad stress in the necrotic portion respectirdy. The decrease volume in small necrotic area （90°） is marked（38% ）, while in big necrotic area （150°） it was indistinctive（ 10% ）. In the same necrotic portion,the decrease volume with titanium was（38% ） larger than with the fibula （37%）, and also larger than with the polyactide（29% ）. Conclusion： In necrotic portion of femoral head, the badshess could produce 13 times of the normal one. Grafting with titanium, fibula and polyactide could reduce the bad stress respectively. The effect of titanium is most marked, second is fibula and polyactide is indistinctive. The effect was in big necrotic portion is bad, the best effect was in small necrotic portion.

EXPERIMENTAL STUDY ON FREE VASCULARIZED FIBULA GRAFTING IN REVASCULARIZING FEMORAL HEAD

laterals or femoral head and neck of 18 mature healthy male domestic dogs were divided into two groups by the principle or auto-control.Avascular osteonecrosis of femoral head(ONFH)and old femoral neck fracture(FNF)were made respectively.Free vascularized fibula grafting was performed 2 weeks later.Arter operation, X-ray,histopathological,electron microscopic,tetracycline fluorescence labelling and99mTc-methylene diphosphorate scanning were carried out respectively.The result indicated that free vascularized fibula grarting could provide new blood supply system to injured femoral head and participate in the repairing process of avascular uecrosis of femoral head.

Research Progress of Tonifying Kidney and Promoting Blood Circulation in the Treatment of Steroid-induced Necrosis of Femoral Head

Osteonecrosis of the femoral head is a common disability disease of the hip joint in China,and osteonecrosis of the femoral head caused by hormone factors is the most common,which is related to the gradual increase in the utilization rate of glucocorticoids in recent years.It is a refractory disease in orthopaedics with a poor prognosis.For this disease,the treatment of traditional Chinese medicine has certain advantages.In view of this,the author reads,analyzes and summarizes its materials by searching China Journal full-text Database and Wanfang Database.This paper reviews the mechanism and clinical research progress of tonifying kidney and activating blood circulation in the prevention and treatment of steroid-induced osteonecrosis of the femoral head,hoping to provide help for the clinical treatment of hormone-related osteonecrosis of the femoral head.

HISTOMORPHOMETRIC STUDY OF SUBCHONDRAL BONE OF NECROTIC FEMORAL HEAD IN RABBITS INDUCED BY METHYLPREDNISOLONE COMBINED WITH LOW-DOSE LIPOPOLYSACCHARIDE

Objective To investigate the histomorphometric features of the necrotic femoral head of rabbits induced by methylprednisolone combined with lipopolysaccharide. Methods Thirty-two mole adult New Zealand white rabbits were used. Among them, 16 were injected with lipopolysaccharide and methylprednisolone （ osteonecrosis group） , and another 16 were sham-injected with saline （ control group）. Magnetic resonance （MR） imaging was taken for femoral heads of the rabbits in both groups at the end of 2, 4 and 6 weeks after the injection. All the rabbits were then killed 6 weeks later. The femoral heads of the rabbits were collected and processed for histological and histomorphometric analysis. Results Femoral head necrosis occurred in 14 rabbits of the osteonecrosis group which were confirmed by histological evaluation and MR imaging. Osteonecrotic femoral heads, compared to controls, were characterized by lower values of bone volume/tissue volume （ P 〈 0. 01 ）, tabecular thichness （ P 〈 0. 01 ） , osteoid surface/bone surface （ P 〈 0. 05 ）, mineralizing apposition rate （ P 〈 0 05 ）, and bone formation rate/bone surface （ P 〈0. 05 ）. However, tabecular separation and eroded surface/bone surface were higher in osteonecrotic femoral heads than in controls （ P 〈 0. 01 ）. Trabecular number and osteoclast surface/ bone surface did not differ significantly. Conclusion The results demonstrated that osteoporosis was apparent in osteonecrotic femoral heads induced by methylprednisolone and lipopolysaccharide, due mainly to trabecular thinning rather than reduction of trabecular number. This might be due to reduced bone formation combined with increased bone resorption.

Effects of Modified Qing'e Pill(加味青娥丸) on Expression of Adiponectin,Bone Morphogenetic Protein 2 and Coagulation-Related Factors in Patients with Nontraumatic Osteonecrosis of Femoral Head

Objective： To observe the regulation of Chinese herbal medicine, Modified Qing＇e Pill（加味青娥丸, MQEP）, on the expression of adiponectin, bone morphogenetic protein 2（BMP2）, osteoprotegerin（OPG） and other potentially relevant risk factors in patients with nontraumatic osteonecrosis of the femoral head（ONFH）. Methods： A total of 96 patients with nontraumatic ONFH were unequal randomly divided into treatment group（60 cases） and control group（36 cases）. The treatment group were treated with MQEP while the control group were treated with simulated pills. Both groups were given caltrate D. Six months were taken as a treatment course. Patients were followed up every 2 months. The levels of plasma adiponectin, BMP2, OPG, von Willebrand factor（vWF）, von Willebrand factor cleaving protease（vWF-cp）, plasminogen activator inhibitor 1（PAI-1）, tissue plasminogen activator（tPA）, C-reactive protein（CRP）, blood rheology, bone mineral density（BMD） of the femoral head and Harris Hip Score were measured before and after treatment. Results： After 6 months of treatment, compared with the control group, patients in the treatment group had significantly higher adiponectin and BMP2 levels（P〈0.01 and P=0.013, respectively）, lower vWF, PAI-1 and CRP levels（P=0.019, P〈0.01 and P〈0.01, respectively）, and lower blood rheology parameters. BMD of the femoral neck, triangle area and Harris Hip Score in the treatment group were significantly higher than those in the control group. Moreover, plasma adiponectin showed a positive association with BMP2（r=0.231, P=0.003） and a negative association with PAI-1（r=–0.159, P〈0.05）. Conclusions： MQEP may play a protective role against nontraumatic ONFH by increasing the expression of adiponectin, regulating bone metabolism and improving the hypercoagulation state, which may provide an experimental base for its clinical effects.

Glucocorticoids affect the metabolism of bone marrow stromal cells and lead to osteonecrosis of the femoral head： a review

Objective To review the recent developments in the mechanisms of glucocorticoids induced osteonecrosis of femoral head （ONFH） and introduce a new theory of ONFH.Data sources Both Chinese- and English-language literatures were searched using MEDLINE （1997-2011）,Pubmed （1997-2011 ） and the Index of Chinese-language Literature （1997-2011 ）.Study selection Data from published articles about mechanisms of glucocorticoids induced ONFH in recent domestic and foreign literature were selected.Data extraction Data were mainly extracted from 61 articles which are listed in the reference section of this review.Results Glucocorticoids are steroid hormones secreted by the adrenal cortex that play a pivotal role in the regulation of a variety of developmental,metabolic and immune functions.However,high dose of exogenous glucocorticoids usage is the most common non-traumatic cause of ON FH.Glucocorticoids can affect the metabolisms of osteoblasts,osteoclasts,bone marrow stromal cells and adipocytes which decrease osteoblasts formation but increase adipocytes formation and cause ONFH finally.Conclusions Glucocorticoids affect the differentiation of mesenchymal stem cells,through activating or inhibiting the related transcript regulators of osteogenesis and adipogenesis.At last,the size and volume of mesenchymal stem cells derived adipocytes will increase amazingly,but the osteoblasts will be decreased obviously.In the meantime,the activity of the osteoclasts will be activated.So,these mechanisms work together and lead to ONFH.

Prevalence of Nontraumatic Osteonecrosis of the Femoral Head and its Associated Risk Factors in the Chinese Population： Results from a Nationally Representative Survey

Background： Nontraumatic osteonecrosis of the femoral head （NONFH） is a debilitating disease that represents a significant financial burden for both individuals and healthcare systems. Despite its significance, however, its prevalence in the Chinese general population remains unknown. This study aimed to investigate the prevalence of NONFH and its associated risk factors in the Chinese population. Methods： A nationally representative survey of 30,030 respondents was undertaken from June 2012 to August 2013. All participants underwent a questionnaire investigation, physical examination of hip, and bilateral hip joint X-ray and/or magnetic resonance imaging exalnination. Blood samples were taken after overnight fasting to test serum total cholesterol, triglyceride, and high-density lipoprotein （HDL） and low-density lipoprotein （LDL） levels. We then used multivariate logistic regression analysis to investigate the associations between various metabolic, demographic, and lifestyle-related variables and NONFH. Results： NONFH was diagnosed in 218 subjects （0.725%） and the estimated NONFH cases were 8.12 million among Chinesepeople aged 15 years and over. The prevalence of NONFH was significantly higher in males than in females （1.02% vs. 0.51%, x^2 = 24.997, P 〈 0.001 ）. Among NONFH patients, North residents were subjected to higher prevalence of NONFH than that of South residents （0.85% vs. 0.61%,x^2= 5.847, P = 0.016）. Our multivariate regression analysis showed that high blood levels oftriglycerides, total cholesterol, LDL-cholesterol, and non-H DL-cholesterol, male, urban residence, family history of osteonecrosis of the femoral head. heavy smoking, alcohol abuse and glucocorticoid intake, overweight, and obesity were all significantly associated with an increased risk of NONFH. Conclusions： Our findings highlight that NONFH is a significantpublic health challenge in China and underscore the need for policy measures on the national level. Furthermore, NONFH shares a number of risk factors with atherosclerosis.

Corticosteroid-induced Osteonecrosis of the Femoral Head:Detection,Diagnosis,and Treatment in Earlier Stages

Objective： This review aimed to provide a current recommendation to multidisciplinary physicians for early detection, diagnosis, and treatment of corticosteroid-induced osteonecrosis of the femoral head （ONFH） based on a comprehensive analysis of the clinical literature. Data Sources： For the purpose of collecting potentially eligible articles, we searched for articles in the PubMed, Cochrane Library, Embase, and CNKI databases up to February 2017, using the following key words： ＆quot;corticosteroid＆quot;, ＆quot;osteonecrosis of the femoral head＆quot;,＆quot;risk factors＆quot;, ＆quot;diagnosis＆quot;, ＆quot;prognosis＆quot;, and ＆quot;treatment＆quot;. Study Selection： Articles on relationships between corticosteroid and ONFH were selected for this review. Articles on the diagnosis, prognosis, and intervention of earlier-stage ONFH were also reviewed. Results： The incidence of corticosteroid-induced ONFH was associated with high doses of corticosteroids, and underlying diseases in certain predisposed individuals mainly occurred in the first 3 months of corticosteroid prescription. The enhanced awareness and minimized exposure to the established risk factors and earlier definitive diagnosis are essential for the success of joint preservation. When following up patients with ONFH, treatment should be started if necessary. Surgical treatment yielded better results than conservative therapy in earlier-stage ONFH. The ideal purpose of earlier intervention and treatment is permanent preservation of the femoral head without physical restrictions in daily living. Conclusions： Clinicians should enhance their precaution awareness of corticosteroid-induced ONFH. For high-risk patients, regular follow-up is very important in the 1st year after high-dose prescription of corticosteroids. Patients with suspected ONFH should be referred to orthopedists for diagnosis and treatment in its earlier stage to preserve the joint.

Pericollapse Stage of Osteonecrosis of the Femoral Head： A Last Chance for Joint Preservation

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 （MR1）, 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 fbr joint-preserving techniques. In tact, 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.