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Biomedical subjects

E N Hanley

Publications and source records attributed to E N Hanley.

At least 19 recordsLinked to original sources
PubMed2003

Cell shape and gene expression in human intervertebral disc cells: in vitro tissue engineering studies.

The objective of the present study was to examine the relation between gene expression and the shape of human intervertebral disc cells cultured in vitro in three-dimensional (3D) scaffolds. Disc cells from 19 subjects were seeded into either a collagen sponge or collagen gel and cultured for 10 days. In situ hybridization was performed on serial sections of paraffin embedded specimens and assessed for expression of selected genes important for extracellular matrix formation: Types I and II collagen, aggrecan and chondroitin-6 sulfotransferase. Rounded cells grown in collagen gel showed expression of Types I and II collagen, aggrecan and chondroitin-6 sulfotransferase; expression of these genes was absent in spindle shaped cells. Cells in the collagen sponge that lay on the sponge margin were frequently spindle shaped; these cells expressed type I collagen, but not type II collagen, aggrecan or chondroitin-6 sulfotransferase. Results presented here provide novel data concerning disc cell gene expression with collagen 3D constructs. This information is useful for future tissue engineering studies that have the challenging goal of selectively modulating gene expression.

Adult↗
PubMed2002

Tenascin in the human intervertebral disc: alterations with aging and disc degeneration.

Our objective for this study was to determine the presence and distribution of tenascin in the human intervertebral disc. The tenascins are a family of extracellular matrix proteins with repeated structural domains homologous to epidermal growth factor, fibronectin type III and the fibrinogens. Little is known about the presence of this protein in the disc. Ten normal human discs donated from subjects newborn to 15 years old, 10 control discs from adult donors aged 24-41 years, and 11 surgical disc specimens from patients aged 26-76 years were examined for immunolocalization of tenascin. In young discs, tenascin was localized throughout the annulus; in the nucleus, localization was confined to pericellular matrix. In adult control and degenerating disc specimens, tenascin in the annulus was localized primarily in pericellular matrix regions encircling either single cells or clusters of disc cells; in rare instances localization was more diffuse in the intraterritorial matrix. In young, healthy disc, tenascin was abundant throughout the annulus. In contrast, degenerating discs in adults showed a localization restricted to the pericellular, and rarely, more restricted intraterritorial matrix. These observations indicate that changes in the amount and distribution of tenascin may have a role in disc aging and degeneration, possibly by modulating fibronectin-disc-cell interactions, and causing alterations in the shape of disc cells.

Adolescent↗
PubMed2002

An improved staining method for intervertebral disc tissue.

The objective of this study was to design a new staining procedure for human disc tissue for visualizing both collagen and proteoglycan-matrix components on the same histology section. Weigert's hematoxylin, alcian blue and picrosirius red were combined to produce distinctive staining of collagen (red), proteoglycans (blue) and cellular elements of the intervertebral disc. This novel stain reveals sharp details of collagen composition in the perilacunar, territorial and intraterritorial extracellular matrix, and concomitantly demonstrates the presence of proteoglycan accumulations around cells in the lacunar spaces and in the extracellular matrix. These details reveal variations within the tissue that would not be apparent with routine stains.

Adult↗
PubMed2001

Clinical and demographic prognostic indicators for human disc cell proliferation in vitro: pilot study.

STUDY DESIGN: Human anulus cells were cultured under control and experimental conditions to study associations between proliferation and clinical-demographic features of subjects from which cells were obtained. Statistical multiple regression analyses were applied to develop mathematic models relating proliferation to age, gender, Thompson score (denoting stage of disc degeneration), and status (control donor [postmortem]; surgical patient). OBJECTIVES: To identify the effect of donor characteristics on proliferative capacities of human disc cells. SUMMARY OF BACKGROUND DATA: As therapeutic options for disc degeneration increase, novel biologic options are important future considerations. Little is known about the influence of clinical-demographic features on cell proliferation. METHODS: Anulus cells were studied in two designs: 1) Cells from 12 individuals were grown in monolayer with 50 ng/mL interleukin growth factor-1 (IGF-I), 100 ng/mL insulin, or control conditions. 2) Cells from nine individuals were grown in three-dimensional culture with 10 ng/mL IGF-I or control conditions. Cell proliferation data and data on age, gender, Thompson score, and status were collected. Standard statistical analyses were used to develop correlation models. RESULTS: Data from monolayer experiments produced significant models fitting proliferation in the presence of low serum, 50 ng/mL IGF-I, or insulin, with age, gender, Thompson score, and status (respective R2: 0.827, 0.680, 0.850). Three-dimensional cultures exposed to 10 ng/mL IGF-I resulted in proliferation that correlated in a significant negative manner with Thompson score (r = -0.798). CONCLUSIONS: Clinical-demographic prognostic indicators may help predict levels of proliferation. Greater age, greater disc degeneration, female gender, and surgical derivation had deleterious effects on proliferation potential in this model.

Adolescent↗
PubMed2001

Morphologic and molecular evidence for gap junctions and connexin 43 and 45 expression in annulus fibrosus cells from the human intervertebral disc.

Data are presented which provide evidence for gap junction formation and connexin (Cx) 43 and 45 gene expression in human intervertebral disc cells in vivo and in vitro. These findings in cells from the annulus are important in conjunction with the well-recognized loss of disc cells during aging and disc degeneration. As a result of this loss of cells, cell-cell communication, which we propose is an important, but as yet poorly understood, mechanism which links and coordinates cellular function throughout the entire population of disc cells, is also disrupted. These studies provide additional information on the fundamental cell biology of the disc cell and provide an additional framework for understanding aging, degeneration and potential repair of the human disc.

Aged↗
PubMed2000

Human disc cells in monolayer vs 3D culture: cell shape, division and matrix formation.

BACKGROUND: The relationship between cell shape, proliferation, and extracellular matrix (ECM) production, important aspects of cell behavior, is examined in a little-studied cell type, the human annulus cell from the intervertebral disc, during monolayer vs three-dimensional (3D) culture. RESULTS: Three experimental studies showed that cells respond specifically to culture microenvironments by changes in cell shape, mitosis and ECM production: 1) Cell passages showed extensive immunohistochemical evidence of Type I and II collagens only in 3D culture. Chondroitin sulfate and keratan sulfate were abundant in both monolayer and 3D cultures. 2) Cells showed significantly greater proliferation in monolayer in the presence of platelet-derived growth factor compared to cells in 3D. 3) Cells on Matrigel(tm)-coated monolayer substrates became rounded and formed nodular colonies, a finding absent during monolayer growth. CONCLUSIONS: The cell's in vivo interactions with the ECM can regulate shape, gene expression and other cell functions. The shape of the annulus cell changes markedly during life: the young, healthy disc contains spindle shaped cells and abundant collagen. With aging and degeneration, many cells assume a strikingly different appearance, become rounded and are surrounded by unusual accumulations of ECM products. In vitro manipulation of disc cells provides an experimental window for testing how disc cells from given individuals respond when they are grown in environments which direct cells to have either spindle- or rounded-shapes. In vitro assessment of the response of such cells to platelet-derived growth factor and to Matrigel(tm) showed a continued influence of cell shape even in the presence of a growth factor stimulus. These findings contribute new information to the important issue of the influence of cell shape on cell behavior.

Journal Article↗
PubMed2000

Anti-apoptotic effects of IGF-1 and PDGF on human intervertebral disc cells in vitro.

STUDY DESIGN: Human cells from the anulus were grown in tissue culture in an experimental design to study the anti-apoptotic effect of two selected cytokines. OBJECTIVES: To determine whether two selected cytokines, insulin-like growth factor-1 and platelet-derived growth factor, were effective in decreasing apoptosis in human cells from the anulus grown in culture for 10 days. SUMMARY OF THE BACKGROUND DATA: Previous studies have shown that there is a small cell population in the aging human intervertebral disc. Earlier work from the authors' laboratory suggested that apoptosis (programmed cell death) may be a major contributing factor to the decrease in cell number. A wide variety of inhibitors of apoptosis have now been identified; the present report presents findings on the actions of insulin-like growth factor-1 and platelet-derived growth factor in retarding or preventing apoptosis. METHODS: Using previously published culture methods, cells from the anulus of 25 subjects (mean age, 41.7 years) were grown in monolayer culture for 10 days and tested under the following conditions: 1) control growth in the presence of 20% fetal bovine serum; 2) positive control conditions promoting the development of apoptosis in the absence of serum; or 3) in dose-response regimes where insulin-like growth factor-1 or platelet-derived growth factor were added in the presence of only 1% fetal bovine serum (necessary for basal cell maintenance). Specimens were derived from 18 lumbar, 9 cervical, and 1 thoracic sites; the average Thompson score was III. Cells were grown on chambered slides and evaluated in situ using the TdT in situ apoptosis detection reaction to identify apoptotic cells. An average of 300 cells were counted in replicate cultures at each dose to determine the incidence of apoptosis; results were analyzed with standard statistical techniques. Cultured cells also were examined with transmission electron microscopy. RESULTS: Serum withdrawal to a 1% level was used as a positive apoptosis control in vitro and resulted in a significantly greater percentage of apoptosis compared with the 20% serum negative control (1.02% +/- 0.34 (28) versus 0.14% +/- 0. 04 (27; mean +/- SEM (n)), P < 0.0001). Exposure to 50 ng/mL insulin-like growth factor-1 significantly reduced the percentage of apoptosis (vs.- 1% serum) to 0.49% +/- 0.26 (P = 0.005); 500 ng/mL was also significantly effective (% apoptosis = 0.09% +/- 0.04 (P = 0.0001). Platelet-derived growth factor at a dose of 100 ng/mL also significantly reduced apoptosis (0.18 +/- 0.11, P = 0.0001). CONCLUSIONS: Data demonstrate a significant reduction in the percentage of apoptotic disc cells after exposure to 50-500 ng/mL insulin-like growth factor-1 or exposure to 100 ng/mL platelet-derived growth factor. These findings expand the understanding of the cell biology of the disc cell and show that selected cytokines can retard or prevent programmed cell death in vitro. The administration of these cytokines may have future therapeutic potential in the treatment of disc degeneration.

Adolescent↗
PubMed2000

Effects of very high antibiotic concentrations on human intervertebral disc cell proliferation, viability, and metabolism in vitro.

STUDY DESIGN: Four antibiotics commonly used during spinal surgery (cefazolin, gentamycin, cefamandole, and vancomycin) were tested for their effects on cultured human disc cells from the anulus. OBJECTIVE: To determine the viability, proliferation, and metabolism of cells cultured from the human anulus after they were exposed to four antibiotics. SUMMARY OF BACKGROUND DATA: Previous studies concerning the effect of antibiotics on the disc have used animal models or explanted discs, but little is understood about the effect of antibiotics on the proliferation, viability, and metabolism of cells from the anulus. METHODS: In this study, 3H-thymidine incorporation, trypan blue exclusion, and cell metabolism were determined using cells from the human anulus grown in monolayer culture. The latter measurement used a cytosensor microphysiometer to monitor the rate at which cells acidified their microenvironment, an event that is proportional to cellular metabolism because it reflects the excretion over time of acidic products such as lactic acid from glycolysis and CO2 from cellular respiration. RESULTS: After 48 hours of antibiotic exposure, cell viability was significantly lower as a result of all four antibiotics at the highest concentration tested. Cell proliferation was lower after exposure to cefazolin and cefamandole. During a 6-hour antibiotic exposure, anulus cells in the highest concentration of cefamandole or vancomycin displayed a significantly decreased rate of cell metabolism. CONCLUSIONS: These findings show that high doses of antibiotics can have direct, deleterious effects on cultured disc cell survival, cell proliferation, and metabolic rates. Discitis is a serious primary or postoperative complication that often requires prolonged antibiotic treatment. Studies such as the current investigation with cultured cells from the anulus show the importance of a greater understanding concerning antibiotic effects on disc cell proliferation and metabolism.

Adult↗
PubMed2000

Optimization of 5-(and-6)-carboxyfluorescein diacetate succinimidyl ester for labeling human intervertebral disc cells in vitro.

We have assessed the utility of an intracellular fluorochrome, 5-(and-6)-carboxyfluorescein diacetate succinimidyl ester (CFSE), as a tracking label for human intervertebral disc cells in vitro. Although 5 microM provides adequate intracellular labeling for whole cell fluorescent microscopic identification of labeled cells, 20 microM was preferable for immunocytochemical localization of paraffin embedded labeled cells. Electron dense vesicles are seen at the ultrastructural level in labeled cells. Discrete vesicular labeling can also be observed in whole cell mounts viewed with fluorescence microscopy. Whole cells retain good label for 6 weeks. CFSE labeling is relatively easy, nontoxic to cells and nonradiocactive. Initial optimization of dose with specific cells types is recommended when confirmation of positive immunocytochemistry is needed for tissue engineering studies.

Cell Survival↗
PubMed1999

Lumbar spinal fusion using recombinant human bone morphogenetic protein in the canine. A comparison of three dosages and two carriers.

STUDY DESIGN: A randomized, prospective and controlled animal study. OBJECTIVE: To evaluate lumbar spinal fusion using recombinant human bone morphogenetic protein 2 in a canine model. SUMMARY OF BACKGROUND DATA: Spinal fusion using autogenous bone grafting is associated with donor site morbidity and a nonunion rate of 5% to 35%. The use of recombinant human bone morphogenetic protein 2 as a bone graft substitute would eliminate donor site morbidity and perhaps augment the rate of successful fusion. METHODS: Mature beagles underwent bilateral paraspinal exposure at L4-L5, followed by transverse process decortication and randomization into one of six groups using differing doses of recombinant human bone morphogenetic protein 2 implanted using either a Type I collagen carrier or a polylactic acid carrier. Two control groups were used: one group without recombinant human bone morphogenetic protein 2 and another group using autogenous rib graft alone. RESULTS: Groups treated with recombinant human bone morphogenetic protein 2 demonstrated complete fusion in all animals. Animals treated with collagen carrier alone (no recombinant human bone morphogenetic protein 2) demonstrated complete absence of fusion. Successful fusion occurred in one of three canines in the autogenous bone graft group. Fusion masses in the recombinant human bone morphogenetic protein 2 treatment groups were significantly larger in size at 3 months than in the autogenous bone graft group. The collagen carrier was more biocompatible and biodegradable because residual polylactic acid carrier was seen with adjacent multinucleated giant cells. There was no evidence of spinal canal or nerve root encroachment in the recombinant human bone morphogenetic protein 2 treatment groups. CONCLUSIONS: The use of recombinant human bone morphogenetic protein 2 implanted using a Type I collagen carrier resulted in 100% fusion without adverse effects.

Animals↗
PubMed1999

Safety of recombinant human bone morphogenetic protein-2 after spinal laminectomy in the dog.

STUDY DESIGN: This was a randomized, blinded trial of the safety of the application of recombinant human bone morphogenetic protein (rhBMP)-2 or autologous bone graft onto a laminectomy defect of the dog in the presence or absence of a dural membrane puncture. OBJECTIVE: To test the safety of rhBMP-2 in an application in which direct contact of the material with neural tissue occurs. SUMMARY OF BACKGROUND DATA: Application of rhBMP-2 in laboratory animals stimulates local bone formation to effect spinal fusion and healing of segmental bone defects. The use of rhBMP-2 as a bone graft substitute in spinal fusion would eliminate donor site morbidity and may augment the rate of successful fusion. Because rhBMP-2 may unintentionally come in contact with neural tissue, the consequences of such a safety issue must be addressed in an animal model before human trials. METHODS: Twenty skeletally mature beagles underwent spinal exposure followed by bilateral laminectomy at L5. In half of the dogs, a puncture wound was made to the dura with the expression of cerebrospinal fluid at the site of the puncture. In randomly selected animals, the exposed dural elements received either autologous bone graft with the bone removed from the laminectomy site or an implant of the rhBMP-2 device. The animals was observed for 12 weeks with periodic clinical examinations and monthly computed tomographic scans. RESULTS: There was no clinical, radiographic, or histologic evidence of neurologic abnormalities in these animals. The rhBMP-2 stimulated bone growth in the laminectomy defect and came into direct contact with the dural membrane. There was no evidence of abnormal mineralization within the thecal sac or in the spinal cord itself. CONCLUSIONS: The rhBMP-2 implant stimulated bone formation in the laminectomy site. Neither autologous bone, rhBMP-2, nor the dural puncture had deleterious consequences for the animals.

Administration, Topical↗
PubMed1999

The influence of Matrigel or growth factor reduced Matrigel on human intervertebral disc cell growth and proliferation.

Matrigel (reconstituted basement membrane extract) is a potent inducer of cell growth and differentiation in vitro. This study examined phenotypic variation and proliferative responses of human annular intervertebral disc cells in vitro in Matrigel and Growth Factor Reduced Matrigel (GFR-Matrigel). Cells from age- and gender-matched control subjects and patients with degenerative disc disease were grown either on the surface of, or suspended within, either matrices. Disc cells grew well on top of both matrices with cells spontaneously forming cell projections. Cells grown within either matrix migrated within the gel to form colonies. Increased colony formation within the matrices was seen with young control and patient cells (p < 0.05). Old and young control and patient cells showed increased proliferation within GFR-Matrigel compared to Matrigel. When grown on the matrix surface, young patient and control donor cells showed increased proliferation on GFR-Matrigel compared to Matrigel. Cellular proliferation was significantly greater inside a 3-dimensional environment than a two-dimensional surface monolayer environment. Disc cells had increased proliferation when grown in or on GFR-Matrigel compared to Matrigel. These studies serve as a baseline for subsequent investigations regarding effects of cytokines on disc cells and increase our knowledge of the influence of extracellular matrices on disc cell proliferation.

Adult↗
PubMed1998

Analysis of aging and degeneration of the human intervertebral disc. Comparison of surgical specimens with normal controls.

STUDY DESIGN: A prospective analysis of 33 control and 39 surgical human lumbar disc specimens from the anulus was undertaken to assess disc cell extracellular matrix production and cell function. The authors of this study analyzed immunohistochemical distributions of Types I, II, III and VI collagen, in situ localization of apoptotic disc cells, and tartrate-resistant acid phosphatase localization. OBJECTIVES: To quantify the incidence of apoptotic cell death in the anulus; examine the collagen distribution in the pericellular, territorial, and interterritorial matrix; examine matrix cell degeneration; and compare diseased tissue with normal tissue from control individuals. SUMMARY OF THE BACKGROUND DATA: Previous studies of disc histopathology have focused on extracellular matrix morphology and on biochemical synthetic and degenerative changes, but little is understood about the cell populations within the disc that are responsible for these changes. METHODS: In this study light microscopy, immunohistochemistry, enzyme histochemistry, and in situ hybridization were used to examine 33 patient and 39 control specimens of human anulus obtained either via surgical procedures or from donors to the Cooperative Human Tissue Network. RESULTS: The high incidence of apoptotic cell death was significantly greater in the control group (73.1 +/- 5.1% [mean +/- SEM]; n = 20) than among surgical specimens (53.5 +/- 5.6%; n = 20; P < 0.001); this was probably a result of the significantly greater average age in the control population (57.2 +/- 3.1 years) compared with that in the patient population (44.3 +/- 3.2 years; P < 0.001). Immunohistochemistry yielded findings that led to an expanded appreciation of the greatly modified extracellular domains that surrounded disc cells during aging and degeneration in both study groups. Enzyme histochemistry revealed the presence of tartrate-resistant acid phosphatase activity in human disc cells. CONCLUSIONS: These findings reveal that there is a high incidence of apoptosis in the intervertebral disc. Surviving cells are not synthetically inactive but are, rather, producing inappropriate matrix products during aging and degeneration. In certain instances it appears that the matrix surrounding the cell may form an isolation barrier, which may influence individual cell activity and intercellular communication. These results point to the need to 1) more fully understand the cause of disc cell death via apoptosis and to determine whether this programmed cell death can be reversed or halted, and 2) more fully understand the dynamic relation between disc cells and the surrounding extracellular matrix, which they produce and remodel. The factors regulating extracellular matrix-disc cell homeostasis in the disc are unknown, as is the relation between extracellular matrix and disc cell functional modulation. The morphologic findings of this study suggest that these issues are important considerations in disc cell biology. The identification of tartrate-resistant acid phosphatase activity in disc cells allows for a new area of study of disc extracellular matrix remodelling. In summary, these new perspectives provide new parameters with which to assess disc cell health and function.

Adult↗
PubMed1997

Human intervertebral disc cells from the annulus: three-dimensional culture in agarose or alginate and responsiveness to TGF-beta1.

Cell culture procedures were developed for use with surgical and normal control specimens of the annulus of the human intervertebral disc. Cells were established in monolayer explant culture and seeded into three-dimensional growth environments of alginate or agarose; under these growth conditions cells assumed a rounded phenotype and formed colonies. A novel method of layering suspensions of cells onto cell well inserts proved technically much easier than the microbead culture method. Immunohistochemistry was utilized to demonstrate in vitro production of the following extracellular matrix components: types I, II, III, and VI collagen, 4-S-chondroitin sulfate, and keratan sulfate. Young and old age- and gender-matched cells grown in the presence of TGF-beta1 showed significant enhancement of proliferation after 4 days of exposure to TGF-beta with a lessened mitogenic response present after 10 days. Molecular studies of proteoglycan gene expression showed that at 4 days young normal cells had increased biglycan, but not decorin, message levels. Decorin expression was unchanged at Day 4 and decreased or shut off by Day 10. Results support the use of three-dimensional culture systems for in vitro evaluation of human disc cell function and expand our understanding of the in vitro behavior of these cells.

Adult↗
PubMed1997

Characterization and phenotypic stability of human disc cells in vitro.

Successful in vitro studies of disc cells require interaction of the cell with a compatible microenvironment which favors expression of the disc cell phenotype. The objective of this study was to characterize cells grown by standardized methods of isolation and passage, and culture cells from the human annulus in three-dimensional culture. Cells from the annulus of 11 individuals were cultured in alginate or agarose for ten days, and extracellular matrix components were evaluated with immunohistochemistry and quantitative analysis of the percent of colonies producing Type I or II collagen, 4-sulfated chondroitin sulfate or keratan sulfate. Results show production of these four extracellular matrix products through multiple passages and support the phenotypic stability of disc cells in three-dimensional culture.

Analysis of Variance↗
PubMed1996

Interaction of tobramycin and pH in cultured chick tibiae.

The toxicity of tobramycin at concentrations released from antibiotic-impregnated polymethylmethacrylate beads was determined using cultured embryonic chick tibiae. Because previous results from this laboratory have shown that osteoblast metabolism is inhibited at low pH and because of the potential for a low local pH in infected bone, the antibiotic was tested in medium with pH values from 6.8 to 7.4. Bone metabolism was evaluated by measuring the rates of glycolysis (lactate production), protein synthesis ([3H]proline uptake), and collagen synthesis ([3H]proline hydroxylation). Tobramycin at the concentrations released from the beads (1.0-1.5 mg/ml) contributed to lowering the pH of the medium. At pH 7.4, the antibiotic produced as much as a 30, 39, and 48% decrease in glycolysis, protein synthesis, and collagen synthesis, respectively. Tibiae exposed to tobramycin for 3 days, followed by 2 days without the antibiotic, showed only a partial recovery from its toxic effects. Although tobramycin was relatively less toxic in an acidic environment, the overall metabolic activity of the bones was poorest when the tobramycin concentration was high (2.0 mg/ml) and pH was low (6.8). The results of this study support the following conclusions: (a) tobramycin at high concentrations is toxic to bone, (b) a combination of high tobramycin concentration and low pH in the bone microenvironment may greatly inhibit bone metabolism, and (c) treatment and prevention of osteomyelitis by means of tobramycin-impregnated beads may be augmented by preventing the pH from decreasing in traumatized areas.

Animals↗
PubMed1996

Interobserver reliability and intraobserver reproducibility of the modified Ficat classification system of osteonecrosis of the femoral head.

Anteroposterior and lateral plain radiographs of 116 osteonecrotic femoral heads were reviewed to assess the interobserver reliability and intraobserver reproducibility of the modified Ficat classification system. The radiographs were reviewed initially and then again six months later by three adult reconstructive surgeons, two general orthopaedic surgeons, two orthopaedic residents, and one musculoskeletal radiologist. All eight observers agreed on the classification of twenty hips (17 per cent) at both the first and the second review of the radiographs. Paired comparisons revealed a mean interobserver kappa reliability coefficient of 0.46 (range, 0.30 to 0.67) for the first review and 0.45 (range, 0.30 to 0.66) for the second. For all observers, the mean rate of perfect agreement between the first and the second review was 68 per cent (range, 56 to 80 per cent). The mean kappa value for intraobserver reproducibility was 0.59 (range, 0.44 [one of the residents] to 0.73 [one of the general orthopaedic surgeons]). No observer or pair of observers had excellent reproducibility or reliability (kappa > 0.75). The poor interobserver reliability and fair intraobserver reproducibility diminishes any meaningful comparison of studies in which the modified Ficat classification system has been used and illuminates the need for a more reliable and reproducible classification system.

Femur Head Necrosis↗