Bilateral pericapsular end nerve blocks for steroid-induced avascular necrosis following COVID-19 infection requiring bilateral total hip replacement

BACKGROUND Osteonecrosis or avascular necrosis(AVN)of the hip was one of the dreaded complications of coronavirus disease 2019(COVID-19),which emerged in patients who received steroid therapy.Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients.Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous(IV)or oral dexamethasone,methylprednisolone or hydrocortisone.The use of such high doses of corticost-eroids has shown very positive results and has been lifesaving in many cases.Still,long-term consequences were drug-induced diabetes,osteoporosis,Cushing syndrome,muscle wasting,peripheral fat mobilization,AVN,hirsutism,sleep disturbances and poor wound healing.A significant number of young patients were admitted for bilateral total hip replacements(THR)secondary to AVN following steroid use for COVID-19 treatment.AIM To assess the efficacy of bilateral pericapsular end nerve group(PENG)blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.METHODS This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals,Hyderabad,India.Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months.All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.RESULTS The duration of surgery was 2.5 h on average.Seventeen out of twenty patients(85%)had a Visual Analog Score(VAS)of less than 2 and did not require any supplementation.One patient was removed from the study,as he required re-exploration.The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug.Fifteen out of seventeen patients(88.2%)could be mobilized 12 h after the procedure.CONCLUSION Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19,which surfaced in patients who received steroid therapy requiring surgical intervention.Bilateral PENG block is an effective technique to provide post-operative analgesia resulting in early mobilization and enhanced recovery after surgery.

Effect of Yang-Warming and Kidney-Tonifying Prescription on Expression of Osteogenic and Angiogenic Factors and H-Type Vascular Markers in Steroid-Induced Avascular Necrosis of Femoral Head in Rabbits

Objective: To investigate the effect of Yang-warming and Kidney-tonifying Prescription (YKP) on the treatment of steroid-induced avascular necrosis of the femoral head (SANFH) in rabbits. And to further explore whether its therapeutic mechanism is related to the expression of HIF-1α and VEGF (angiogenic factors), BMP2 and Osterix (osteogenic factor), CD31 (type H vascular marker) and MMP13 (bone destruction-related factor). Methods: Twenty-seven healthy male New Zealand white rabbits were divided into a normal group, model group, traditional Chinese medcine (TCM) group (clinical equivalent dose group of YKP), miR-130a inhibitor group and TCM + inhibitor group. The SANFH model was established by combining horse serum with methylprednisolone. After the model is successfully established, TCM group was given 6.44 g/kg·d YKP by gavage, and the miR-130a gene inhibitor group was intraperitoneally injected with 25 mg/kg miR-130a inhibitor, locked nucleic acid (LNA)-anti-miR-130a. TCM + inhibitor group was treated with YKP intragastrically and miR-130a inhibitor intraperitoneally. The rabbits in the normal group and the model group were intragastrically administered with normal saline 10 ml/d. Once a day for 4 weeks. The avascular necrosis was detected by HE staining. The contents of HIF-1α, VEGF, BMP2 and Osterix in rabbit tissues were detected by qRT-PCR kit, and the expression of CD31 and MMP13 was detected by immunofluorescence staining. Results: In the normal group, the surface of the cartilage layer of the femoral head was smooth, the bone trabeculae were intact and densely arranged, the cells of each layer were neatly arranged, the morphology of the bone cells, the chondrocytes and the adipocytes were normal. In the model group, cartilage surfaces of the femoral head showed exfoliative cracks. The bone trabecular structure was loose and incomplete, chondrocytes, osteoblasts and bone marrow cells were significantly reduced, and the number of empty bone traps was significantly increased. In the TCM-treated group, more chondrocytes, thicker cartilage layer, and more regular bone trabeculae were detected as compared to model rabbits. In contrast, the cartilage layer was thinner, the destruction and fracture of bone trabeculae was more serious, chondrocytes and osteocytes were decreased as compared to model group. The expression of HIF-1α, VEGF, BMP2, and Osterix in the model group decreased significantly as compared to the normal group (P Conclusion: YKP can regulate the expression of angiogenic-related factors (VEGF and HIF-α), osteogenic-related factors (BMP2 and Osterix), and H-type vascular marker CD31, resulting in increased expressions of VEGF, HIF-α, BMP2, and Osterix, which promote intra-femoral head revascularization. Meanwhile, YKP decreased the expression of bone-destruction-related factor MMP13, thus enhancing the ability of bone tissue to repair itself. Regulation of these molecules’ expression may be one of the mechanisms of YKP in the treatment of hormonal femoral head necrosis.

Bilateral Avascular Necrosis of the Femoral Head in Renal Transplant Recipient: A Case Report

Osteoarticular complications are common after renal transplantation. The complications may result from the bone condition prior to transplantation or the iatrogenic effects of the treatments administered. These complications lead to significant morbidity and mortality, in addition to chronic pain and functional impairment. We report the clinical case of bilateral avascular necrosis (AVN) of the femoral head in a kidney transplant recipient. Clinical Case: 53-year-old male with a history of chronic hypertension. He underwent chronic hemodialysis for 12 months and was treated with Entecavir for chronic hepatitis B. The patient received a kidney transplant from a non-related living donor. Induction therapy included Thymoglobulin along with tapered corticosteroids, reaching a dose of 5 mg/day after 3 months, Mycophenolate mofetil (2 g/day), and Tacrolimus adjusted based on residual levels. There was good recovery of renal graft function. After six months, the patient reported bilateral hip pain and functional impairment of both lower limbs. Pelvic X-rays showed signs suggestive of bilateral AVN of the femoral heads. The diagnosis was confirmed by MRI. The patient underwent right hip drilling and total left hip replacement (THR). A right THR was performed a year later. Conclusion: AVN constitutes a frequent cause of morbidity and mortality after RT. The pathophysiology of osteonecrosis remains complex and multifactorial. We emphasize the importance of conducting a thorough assessment of bone health in patients both before and after RT.

Gubi Tongxiao granules regulate vasculization and apoptosis to intervene steroid-induced femoral head necrosis in rabbits

Objective:To investigate the effect of Gubi Tongxiao granules on vascular formation and cell apoptosis in the process of glucocorticoid-induced femoral head necrosis.Methods:Thirty experimental New Zealand rabbits were randomly divided into groups.Except the control group,the animal model of steroid-induced femoral head necrosis was established by lipopolysaccharide combined with glucocorticoids.After successful modeling,the experimental group was given Gubi Tongxiao granules intragastric treatment,the model and control group were given the same amount of normal saline intragastric treatment,once a day,for 8 weeks,the experimental animals were sacrificed,the bilateral femoral head of each group was taken out for hematoxylin-eosin staining,and protein CD34,CYR61 and VEGF were immunohistochemical staining localization.TUNEL staining was used to observe the apoptosis of femoral head cells.The expression levels of apoptosis proteins Bax and Bcl-2 were detected by WB.The expression of VEGF eNOs Bax and Bcl-2 genes was analyzed by RT-qPCR.Results:Gubi Tongxiao granules reduced the number of hollow bone lacunae and apoptotic positive cells(P<0.01),and up-regulated the expressions of CD34,CYR61 and VEGF in femoral head tissue.Compared with control group,the expression of pro-apoptotic protein Bax increased and the expression of anti-apoptotic protein Bcl-2,VEGF and eNOs mRAN decreased significantly in the model group(P<0.01),the opposite results were obtained in the experimental group after Gubi Tongxiao granule intervention(P<0.05).Conclusion:Gubi Tongxiao granules can improve the expression of angiogenic genes and regulate apoptosis-related proteins in the bone tissue of rabbit model with steroid-induced necrosis of femoral head,promote angiogenic differentiation and inhibit apoptosis,and thus achieve the effect of treating steroid-induced necrosis of femoral head.

A Rabbit Model of Hormone-induced Early Avascular Necrosis of the Femoral Head

Objective To establish an experimental model of early stage avascular necrosis of the femoral head （ANFH） caused by corticosteroid in adult rabbits and to observe the pathological changes with various imaging techniques. Methods ANFH was induced by a combination of hypersensitivity vasculitis caused by injection of horse serum and subsequent administration of a high dose of corticosteroid. The pathological changes were detected with digital radiography （DR）, computed tomography （CT）, magnetic resonance imaging （MRI）, ink artery infusion angiography, hematoxylin-eosin staining, and immunohistochemistry. Results The imageological and pathological changes corresponded to the clinical characteristics of early stage ANFH. DR showed bilaterally increased bone density, an unclear epiphyseal line, and blurred texture of cancellous bone. CT showed spot-like low-density imaging of cancellous bone, thinner cortical bone, osteoporosis, and an unclear epiphyseal line. MR! showed bone marrow edema and spot-like high signals in T2-weighted imaging in cancellous bone. Ink artery infusion angiography showed fewer obstructed blood vessels in the femoral head. HE staining of pathological sections showed fewer trabeculae and thin bone, an increased proportion of empty osteocyte lacunae, decreased hematopoiesis, thrombosis, and fat cell hypertrophy. Immunohistochemistry showed attenuated expression of vascular endothelial growth factor in osteoblasts and chondrocytes, and on the inner membrane of blood vessels. Conclusion Experimental rabbit model of early stage ANFH caused by corticosteroid can be successfully established and provide the foundation for developing effective methods to treat early stage ANFH.

Experimental Study of Vascular Endothelial Growth Factor Gene Therapy for Avascular Necrosis of the Femoral Head

To explore a new method for the therapy of the avascular necrosis of the femoral head, the recombinant plasmid pCD-hVEGF 165 was mixed with collagen and was implanted in the necrotic femoral head The expression of vascular endothelial growth factor (VEGF) was detected by RNA dot hybridization and immunohistochemical method The repair of the femoral head was observed by histological method The results showed that the expression of VEGF was detectable in the femoral head treated with VEGF gene Angiogenesis in these femoral heads was more abundant than the control Bone repairing was augmented in the femoral head treated with VEGF gene The results suggest that angiogenesis in bone tissue could be augmented by gene transfection of VEGF and bone repairing would be accelerated accordingly

Microstructures and properties of cancellous bone of avascular necrosis of femoral heads

The aim of this study is to investigate microscopic structure and characterize cancellous bone of avascular necrosis of the femoral head （ANFH）. The rabbit model of the ANFH is established. The histopathologic features are studied successfully. The differences between the steroidinjection group （S.G.） and the controlled group （C.G.） are examined, including the weight of rabbits, the hematological examination and the three-dimensional stnactures. It is found that the plasma levels of cholesterol （CHO）, high-density lipoprotein （HDL） and low-density lipoprotein （LDL） in S.G. are lower than those in C.G. when the triglyceride （TG） increased in the S.G.; but the bone mineral content （BMC） and the structural model index （SMI） of the organ and tissue decreased significantly in S.G. Three-dimensional structures of the femoral head are obtained using micro-computed tomography （CT） scanning and the mechanical model is established to analyze the influences of these structural changes on the mechanical properties of the cancellous bone.

BASIC FIBROBLAST GROWTH FACTOR GENE TRANSFECTION TO ENHANCE THE REPAIR OF AVASCULAR NECROSIS OFTHE FEMORAL HEAD

Objective To explore a new method for the therapy of avascular necrosis of the femoral head. Method The recombinant plasmid pCD-rbFGF was mixed with collagen and was implanted in the necrotic femoral head. Expression of basic fibroblast growth factor (bFGF) was examined by RT-PCR and immunohistochemical method. Re-pair of the femoral head was observed by histological and histomorphometric analysis. Result Expression of bFGF was detected in the femoral head transfected with bFGF gene, indicating significant increase of angiogenesis 2 weeks after gene transfection and increased new bone formation 8 weeks after gene transfection on histom-orphometric analysis (P< 0.01). Conclusion Transfection of bFGF gene enhances bone tissue angiogenesis. Repair in osteonecrosis would be accelerated accordingly.

Regulation of Quan Du Zhong capsule on VEGF/bFGF and expression of Bcl‑2/Bax and Caspase‑3 protein in the repairing process of canine femoral head necrosis

Objective:To explore the repair and treatment effect of Quan Du Zhong capsule on necrosis of femoral head in dogs.Methods:Totally 12 beagles were randomly divided into normal group,model group,Quan Du Zhong capsule group and Xianlinggubao capsule group,with three in each group.In addition to the normal group,the other groups established the femoral head necrosis model by liquid nitrogen alternative freezing.The normal group and the model group did not have any intervention during the modeling period,and the Quan Du Zhong group began to receive the Quan Du Zhong by gavage on the day of modeling;Xianlinggubao capsule group was given Xianlinggubao capsule by gavage once a day for 12 consecutive weeks on the day of modeling.The levels of VEGF and bFGF in the blood vessels of each group at the 12th week were compared,and the ratios of BMD,BS/BV,BV/TV,Tb.Th,Tb.N were measured by Micro CT,and the expressions of Bcl-2,Bax,Caspase-3 proteins were detected by immune reaction.Results:1.Compared with the normal group,the level of serum VEGF and bFGF in the model group decreased after 12 weeks of modeling(P<0.05);Compared with the model group,the levels of serum VEGF and bFGF water in the Xianlinggubao capsule group and the Quan Du Zhong capsule group increased on average at the 12th week of modeling,with statistical difference(P<0.05).The level of the Quan Du Zhong capsule group was the highest,followed by the Xianlinggubao capsule group.2.Compared with the normal group,BMD,BS/BV,BV/TV,Tb.Th and Tb.N in the model group were lower,and Tb.SP were higher,the results were statistically significant(P<0.05).Compared with the model group,the BMD,BV/TV,Tb.Th and Tb.N of Xianlinggubao capsule group and the total eucommia capsule group increased,while the BS/BV and Tb.SP decreased(P<0.05).3.The Quan Du Zhong capsule group and Xianlinggubao capsule group could significantly increase the expression of bcl-2 protein in the femoral head of dogs,which was significantly different from the model group(P<0.05).The expression of bax protein in the femoral head of dogs in the Quan Du Zhong capsule group and the Xianlinggubao capsule group was significantly reduced compared with the model group(P<0.05).The expression of caspase-3 protein in the femoral head of dogs was significantly reduced in the Quan Du Zhong capsule group and Xianlinggubao capsule group,which was significantly different from the model group(P<0.05).Conclusion:Quan Du Zhong capsule can increase the expression of VEGF and bFGF in serum,increase the expression of bcl-2,inhibit the expression of bax,and reduce the expression of caspase-3,which plays a synergistic role in the treatment of avascular necrosis of the femoral head,and has potential targets.

De Garengeot hernia with avascular necrosis of the appendix: A case report

BACKGROUND An incarcerated hernia is a common cause of acute abdominal pain.There are various types of incarcerated hernias,including incarcerated hernias of the appendix.These hernias are often complicated by appendiceal inflammation,necrosis,and suppuration,which affect the outcome of surgical repair.A De Garengeot hernia is a femoral hernia that contains the appendix.This type of hernia has a low incidence.When a De Garengeot hernia is clinically suspected,emergency surgical treatment should be performed as soon as possible.CASE SUMMARY A 59-year-old man was admitted to the hospital with a painful right inguinal mass that had suddenly developed 6 hours earlier.Physical examination revealed a 4 cm×2 cm palpable mass in the right groin.The mass was hard and could not be reduced due to tenderness.It did not descend into the scrotum.B-ultrasound revealed an incarcerated hernia.During surgery,the hernia was found to contain the appendix,which exhibited distal avascular necrosis.A De Garengeot hernia was diagnosed according to the classification criteria of this type of inguinal hernia.Laparoscopic reduction of the incarcerated hernia,appendectomy,and small-incision femoral hernia repair were performed in the emergency department,and cefuroxime was administered as anti-infection therapy for 2 d postoperatively.After treatment,the patient had no abdominal pain or infection and was discharged on postoperative day 4.He had no recurrence of the inguinal hernia after 16 months of follow-up.CONCLUSION De Garengeot hernias have a low incidence and are difficult to diagnose.Laparoscopy is useful for their diagnosis and treatment.

Avascular necrosis of the first metatarsal head in a young female adult:A case report and review of literature

BACKGROUND This case study describes an atypical presentation of avascular necrosis(AVN)of the first metatarsal head,which is largely unfounded in the literature.CASE SUMMARY A healthy 24-year-old female initially presented with pain at the first metatarsophalangeal joint(MTPJ)and was diagnosed with AVN by physical examination and magnetic resonance imaging.The patient demonstrated atypically poor progress in recovery,despite being in otherwise good health and being of young age,with no history of corticosteroid or alcohol use.The patient also did not have any history or clinical features of autoimmune disease or vasculitis,such as systemic lupus erythematosus.The patient was managed with conservative treatment for 18 mo,which allowed for gradual return of full range of motion of the first MTPJ and subsiding pain,permitting the patient to return to highintensity sports training and full weight-bearing.Throughout her recovery,many differential diagnoses were ruled out through specific investigations leading to further reinforcement of the diagnosis of AVN of the 1st metatarsal head.CONCLUSION Atypical AVN may occur with no predisposing risk factors.Treatment is mainly conservative,with unclear guidelines in literature on management.

Analysis of the Development of Avascular Necrosis in Slipped Capital Femoral Epiphysis

Introduction: Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents. The most serious complication is avascular necrosis (AVN), which has lasting sequelae. The objective of this study was to determine the rate of AVN in stable slips. Method: We reviewed retrospectively all the children treated for SCFE between 2004 and 2008 at Princess Margaret Hospital. Results: Of a total of 67 patients, 51 (76%) were stable slips and 16 (24%) unstable. Avascular necrosis developed in 3 patients with stable slip (5.9%) and in 6 with unstable slip (37.5%). There was no statistically significant association found between AVN and age, weight, slip severity, pin position, number of pins used, experience of the surgeon or side affected. Those with stable presentations can develop AVN2, males are more likely and the possibility of developing AVN increases as the time from presentation to operation increased. Conclusion: AVN can occur in stable slips without joint penetration. This combined with male sex and increased time to operation, increases the risk of AVN.

Osteonecrosis of the femoral head: An update in year 2012

Osteonecrosis is a phenomenon involving disruption to the vascular supply to the femoral head, resulting in articular surface collapse and eventual osteoarthritis. Although alcoholism, steroid use, and hip trauma remain the most common causes, several other etiologies for osteonecrosis have been identified. Basic science research utilizing animal models and stem cell applications continue to further elucidate the pathophysiology of osteonecrosis and promise novel treatment options in the future. Clinical studies evaluating modern joint-sparing procedures have demonstrated significant improvements in outcomes, but hip arthroplasty is still the most common procedure performed in these affected younger adults. Further advances in joint-preserving procedures are required and will be widely studied in the coming decade.

Modified porous tantalum rod technique for the treatment of femoral head osteonecrosis

AIM: To study a modified porous tantalum technique for the treatment of osteonecrosis of the femoral head.METHODS: The porous tantalum rod was combined with endoscopy,curettage,autologous bone grafting and use of bone marrow aspirates from iliac crest aspiration in 49 patients(58 hips) with a mean age of 38 years.The majority of the patients had idiopathic osteonecrosis,followed by corticosteroid-induced osteonecrosis.Thirtyeight hips were of Steinberg stage Ⅱ disease and 20 hips were of stage Ⅲ disease.Patients were followed for 5 years and were evaluated clinically with the Merle D'Aubigne and Postel score and radiologically.The primary outcome of the study was survival based on the conversion to total hip arthroplasty(THA).Secondary outcomes included deterioration of the osteonecrosis to a higher disease stage at 5 years compared to the preoperative period and identification of factors that were associated with survival.The Kaplan-Meier survival analysis was performed to evaluate the survivorship ofthe prosthesis,and the Fisher exact test was performed to test associations between various parameters with survival.RESULTS: No patient developed any serious intraoperative or postoperative complication including implant loosening or migration and donor site morbidity.During the 5-year follow up,1 patient died,7 patients had disease progression and 4 hips were converted to THA.The 5-year survival based on conversion to THA was 93.1% and the respective rate based on disease progression was 87.9%.Stage Ⅱ disease was associated with statistically significant better survival rates compared to stage Ⅲ disease(P = 0.04).The comparison between idiopathic and non-idiopathic osteonecrosis and between steroid-induced and non-steroid-induced osteonecrosis did not showed any statistically significant difference in survival rates.The clinical evaluation revealed statistically significantly improved Merle d'Aubigne scores at 12 mo postoperatively compared to the preoperative period(P < 0.001).The mean preoperative Merle d'Aubigne score was 13.0(SD: 1.8).The respective score at 12 mo improved to 17.0(SD: 2.0).The 12-mo mean score was retained at 5 years.CONCLUSION: The modified porous tantalum rod technique presented here showed encouraging outcomes.The survival rates based on conversion to THA are the lowest reported in the published literature.

Vascular endothelial growth factor for the treatment of femoral head osteonecrosis: An experimental study in canines

AIM To evaluate the treatment of osteonecrosis of the femoral head(ONFH) with the use of vascular endothelial growth factor(VEGF).METHODS In 30 mature beagles(6 groups of 5 beagles) ONFH was induced cryosurgically and one of the following solutions was administered locally in the femoral head(FH) in each group: Single injection of 500 μg VEGF(t-VEGFμ group); single injection of 500 ng VEGF(t-VEGFn group); continuous delivery of 500 μg VEGF through osmotic micropump(t-VEGFpump-μ group); continuous delivery of 500 ng VEGF through osmotic micropump(t-VEGFpump-n group); single injection of 0.9% sodium chloride(t-NS group), while one group that served as control group did not receive any local solution(No-t group). FHs were retrieved 12 wk postoperatively, underwent decalcification and hematoxylin/eosin and toluidine blue staining. In two canines per group, one half of FH was processed without decalcification and stained with modified Masson Trichrome. Histological sections were observed by light microscopy and measured with a semi-automatized bone histomorphometry system and Bone Volume/Total Volume(BV/TV), Marrow Volume/Total Volume(MaV/TV), and Trabecular Thickness(TbT h) were assessed. Standard and robust tests(Welch, Brown Forsythe) of analysis of variance along with multiple comparisons, were carried out among the categories.RESULTS The untreated(No-t) group had signs of osteonecrosis, whereas the VEGF groups revealed reversal of the osteonecrosis. Statistical analysis of the decalcified specimens revealed a significantly better BV/TV ratio and a higher Tb Th between the VEGF treatment groups(except the t-VEGFn group) and the No-t group or the control t-NS group. Single dose 500 μg VEGF group had significantly better BV/TV ratio and higher Tb Th when compared to the No-t group(50.45 ± 6.18 vs 29.50 ± 12.27, P = 0.002 and 151.44 ± 19.07 vs 107.77 ± 35.15, P = 0.161 respectively) and the control t-NS group(50.45 ± 6.18 vs 30.9 ± 6.67, P = 0.004 and 151.44 ± 19.07 vs 107.14 ± 35.71, P = 0.151 respectively). Similar differences were found for the prolonged VEGF delivery/pump groups of 500 μg and 500 ng. Analysis of the totality of specimens(decalcified/non-decalcified) enhanced the aforementioned differences and additionally revealed significant differences in the comparison of the TbT h.CONCLUSION In an experimental model of ONFH in canines it was found that local treatment with VEGF leads to bone tissue remodeling and new bone formation.

Prevention of Femoral Head Deformity after Ischemic Necrosis Using Ibandronate Acid and Growth Factor in Immature Pigs

Background: Femoral head deformity is the most severe sequela of ischemic necrosis in skeletally immature patients. Development of severe deformity shortens useful survival time of the joint due to the appearance of early degenerative changes. Preservation of the trabecular architecture through inhibition of osteoclastic bone resorption may minimize the development of the deformity in an animal model of ischemic necrosis of the femoral head. Aims: To determine if a highly potent antiabsorptive agent, ibandronate, would inhibit bone resorption during necrotic femoral head repair to avoid subsequent flattening and deformity, to determine if the use of platelet-rich plasma stimulates bone repair and neovascularization of the damaged femoral head, and to evaluate if the combination of both therapies can preserve the femoral head while stimulating new bone formation in an animal model of ischemic necrosis. Methods: Ischemic necrosis of the femoral head was induced by surgical ligature of the circumflex vessels in 10 Landrace pigs. The animals were divided into four different groups and were administered ibandronate acid, platelet-rich plasma, or both. The contralateral, untreated femoral heads with surgical ligature of the circumflex vessels served as the control group. All animals were killed three months after surgery and the femoral head was evaluated both radiographically and histologically. The femur length was measured on radiographs and compared among the groups.Results: Final femoral length was significantly longer in the group treated with a combination of both therapies (platelet-rich plasma-ibandronate acid) compared to the others groups, with a significant difference between groups. The histological findings showed increased osteoblastic activity and thickened trabiculae, a higher rate of neovascularization, and focal hyperplasia greater bone resorption and neovascularization. Only slight changes (femoral length) were observed in the animals that received platelet-rich plasma in situ favoring revascularization that was, however, only seen in the first months of administration. Conclusions: Radiographic and histological studies showed that a combination of both therapies (platelet-rich plasma and ibandronate acid) preserved the trabecular architecture and prevented femoral head deformity in the early phase of ischemic necrosis repair in immature pigs, coinciding with reports by other authors. Clinical Relevance: These findings support the concept that a combination of antiresorptive and anabolic agents can significantly improve bone healing and decrease femoral head deformity following ischemic necrosis in the fragmentation stage. Further studies would be necessary to determine the optimal dose and longterm effectiveness for the use in pediatric patients.

Surgical management of osteonecrosis of the femoral head in patients with sickle cell disease

Sickle cell disease is a known risk factor for osteonecrosis of the hip.Necrosis within the femoral head may cause severe pain,functional limitations,and compromise quality of life in this patient population.Early stages of avascular necrosis of the hip may be managed surgically with core decompression with or without autologous bone grafting.Total hip arthroplasty is the mainstay of treatment of advanced stages of the disease in patients who have intractable pain and are medically fit to undergo the procedure.The management of hip pathology in sickle cell disease presents numerous medical and surgical challenges,and the careful perioperative management of patients is mandatory.Although there is an increased risk of medical and surgical complications in patients with sickle cell disease,total hip arthroplasty can provide substantial relief of pain and improvement of function in the appropriately selected patient.

Nuclear medicine imaging in osteonecrosis of hip:Old and current concepts

Osteonecrosis(ON) is caused by inadequate blood supply leading to bone death, which results in the collapse of the architectural bony structure. Femoral head is the most common site involved in ON. Magnetic resonance imaging(MRI) is a commonly used imaging modality to detect early ON. When MRI is inconclusive, bone scan is helpful in detecting ON during early phase of the disease. As newer nuclear medicine equipment, like single photon emission computed tomography/computed tomography(CT) and positron emission tomography/CT, are emerging in medical science, we review the role of these imaging modalities in ON of femoral head.

Osteonecrosis: The perils of steroids. A review of the literature and case report

Non-traumatic osteonecrosis is a cause of joint pain and deformity, not uncommonly caused by corticosteroid use. Despite this, corticosteroid induced osteonecrosis is poorly represented in the literature. We performed a detailed review of corticosteroid induced osteonecrosis, including aetiology, prevention, screening, clinical presentation, investigations, staging systems and treatment. We present this in the context of a patient at our institution who developed bilateral hip, shoulder and knee osteonecrosis following high dose corticosteroid therapy for dermatomyositis.