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PubMed1999

Symptomatic multifocal osteonecrosis. A multicenter study. Collaborative Osteonecrosis Group.

Osteonecrosis of the femoral head frequently occurs in a young population (mean age, approximately 35 years) and may lead to disabling arthritis requiring hip arthroplasty surgery. This disease is compounded when it has concurrent involvement of other joints. Multifocal osteonecrosis is defined as disease involving three or more anatomic sites. The purpose of this study was to review the demographic, clinical, radiographic staging patterns, and treatment options in patients with multifocal osteonecrosis to facilitate earlier diagnosis and optimize treatment. Twenty-one centers participated by submitting completed data forms on patients under their care after review of their databases. One hundred one patients were identified. Patient demographics, associated diseases, corticosteroids and other medications used, presenting joints, and symptomatology were evaluated. Radiographs and magnetic resonance imaging scans or both were used to diagnose and stage osteonecrotic lesions. Ninety-two of the 101 (91%) patients had a history of corticosteroid therapy. Twelve patients (of 14 tested) were found to have a coagulation disorder. All 101 patients had femoral head involvement. Osteonecrosis also was seen in the knee (96%), shoulder (80%), ankle (44%), and seven other sites. Overall, 631 joints were involved (6.2 lesions per patient). Bilaterality was common: hips, 98%; knees, 86%; and shoulders, 83%. Most lesions (69%) were in a precollapse stage at the time the patients presented for treatment. In eleven patients, the knee was the sole presenting symptomatic joint, and the shoulder and ankle were the sole presenting symptomatic joints in five and four patients, respectively. An improved understanding of the epidemiology, pathogenesis, and etiology of multifocal osteonecrosis will facilitate the diagnosis and treatment of this disease. In patients with osteonecrosis of the hip, all symptomatic joints should be evaluated with radiographs. In patients with osteonecrosis presumably not involving the femoral head, the patient's femoral heads should be evaluated radiographically, regardless of whether the hips are symptomatic.

Adolescent↗
PubMed2003

Osteonecrosis of the femoral head of laboratory animals: the lessons learned from a comparative study of osteonecrosis in man and experimental animals.

Animal models of osteonecrosis of the femoral head are indispensable to the understanding of successful treatment modalities for avascular necrosis of the femoral head in adults and in children with Legg-Calvé-Perthes disease. Many of these models adequately reflect the current "vascular deprivation" theory regarding the etiology of the disease. In addition to spontaneous occurrence, surgical- and corticosteroid-induced models are suitable, common experimental ones. Osteonecrosis of spontaneously hypertensive rats appears to be due to defective bone formation and compression of the arteries entering the femoral head at its lateral facets by daily weight-bearing loads. Successful modeling of surgical-induced femoral capital necrosis can be a challenge in animals with a dual epiphyseal blood supply. High doses of corticosteroids are a pivotal risk factor in the development of osteonecrosis. The pathogenesis of corticosteroid-induced osteonecrosis likely resides in reduced blood flow. Steroids may reduce blood flow by numerous mechanisms, including marrow adipocytic hypertrophy leading to sinusoidal compression, venous stasis and, eventually, obstruction of the arteries, and arterial occlusion by fat emboli and lipid-loaded fibrin-platelet thrombi. Other, less common varieties of osteonecrosis include those secondary to endotoxin-induced disseminated intravascular coagulation, immune reactions, immoderately low or high temperatures, and high-impact-related injuries. Common to these diverse forms of osteonecrosis are fibrin thrombi clogging arterioles and small arteries.

Animals↗
PubMed2006

Prevalence of bisphosphonate associated osteonecrosis of the jaw within the field of osteonecrosis.

OBJECTIVES: Prevalence of bisphosphonate-associated osteonecrosis of the jaws within the catchment area of a university hospital maxillofacial unit and to review the outcome of treatment. METHODS: In a retrospective study, all patients with osteonecrosis, osteomyelitis and osteoradionecrosis treated in the period from January 2000 to March 2005 in the department for Maxillo Facial Surgery at the University of Mainz, Germany were analysed. RESULTS: Forty percent of the patients are grouped to odontogenic or surgically induced osteomyelitis. The second largest group (28%) were patients with osteoradionecrosis (ORN). Ten percent of all patients developed an osteonecrosis after treatment with bisphosphonates (BOJ). Eight percent showed osteomyelitis or sequester due to a trauma while 14% of all patients had osteomyelitis of unknown origin. All BOJ patients took bisphosphonates because of metastatic diseases of the bone (plasmocytoma, mamma carcinoma and prostate cancer) for up to 5 years. All had been administered a nitrogen-containing bisphosphonate (either pamidronat or zoledronat). Thirteen out of the 17 patients with BOJ and 14 of the 45 with ORN reported a possible trigger like previous tooth extraction, pressure denture sore or periodontal diseases. CONCLUSION: These findings support the association of bisphosphonate therapy and osteonecrosis of the jaw. The importance of this new disease is characterised by the growing number of patients. The role of dental trigger factors and the poor surgical outcome both seem to justify a prophylactic dental care concept in high-risk patients.

Aged↗
PubMed2002

Bone scintigraphy screening for osteonecrosis of the shoulder in patients with non-traumatic osteonecrosis of the femoral head.

OBJECTIVE: In patients with non-traumatic osteonecrosis of the femoral head (ONFH), the shoulder is one of the major affected sites secondary to the proximal and distal femur in cases of multiple osteonecrosis. The present study attempted to investigate whether technetium bone scintigraphy is useful for screening of non-traumatic osteonecrosis of the shoulder (ONS). DESIGN AND PATIENTS: A total of 170 shoulder joints in 85 patients with ONFH were evaluated by bone scintigraphy and the findings compared with those of magnetic resonance imaging (MRI). The MR diagnosis was used as the gold standard. RESULTS: Based on the diagnosis by MRI, ONS was detected in 43 shoulders of 27 patients (25%). All necrotic lesions were located in the humeral head. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value of bone scintigraphy for ONS detection were 65%, 81%, 77%, 54% and 87%, respectively. When the necrotic angle of the lesions on the mid-coronal MRI was more than 40 degrees, the sensitivity of bone scintigraphy for ONS detection increased to 88% (21/24 shoulders). CONCLUSION: Bone scintigraphy may be useful for demonstrating medium or large ONS lesions on screening of patients with ONFH.

Adolescent↗
PubMed2000

Osteonecrosis of the patella in patients with nontraumatic osteonecrosis of the femoral head: MRI findings in 60 patients.

We examined both knees in 60 patients with nontraumatic osteonecrosis of the femoral head with three-dimensional MRI. We found osteonecrosis of the patella in 9 patients (10 knees) and osteonecrosis of the femoral or tibial condyles/metaphyses in 35 patients (61 knees). In the patella, the necrosis was located in the proximal half and tended to develop in patients with other necrotic lesions in the knee.

Adolescent↗
PubMed2001

Bone scintigraphy for osteonecrosis of the knee in patients with non-traumatic osteonecrosis of the femoral head: comparison with magnetic resonance imaging.

OBJECTIVE: To determine whether technetium bone scintigraphy (BS) is useful for screening of non-traumatic osteonecrosis of the knee (ONK), which was a major affected site, secondary to the femoral head, among multiple osteonecrosis, in patients with non-traumatic osteonecrosis of the femoral head (ONFH). METHODS: A total of 214 knee joints in 107 patients with ONFH were evaluated by BS and a comparison made with magnetic resonance imaging (MRI). ONK was classified into five sites, including the femoral condyles (ONFC), distal femoral metaphysis (ONFM), tibial plateau (ONTP), proximal tibial metaphysis (ONTM), and patella (ONP). RESULTS: Based on the diagnosis by MRI, ONK was detected in 103 knees of 62 patients (48%). ONFC was most common (86 knees, 40%), ONFM (15%), followed by ONTM (10%), ONP (3%), and ONTP (0.9%). Sensitivity, specificity, and accuracy of BS for ONFC detection were 63%, 71%, and 68%, respectively. When the ONFC lesions on the coronal views of MRI were large or medium sized and occupied two thirds, or the entire anteroposterior joint surface on the sagittal views, the sensitivity of BS for ONFC detection increased to 89% (34/38 knees). The sensitivity of BS for ONFM, ONTM, and ONP detection was 3%, 0%, and 0%, respectively, but these lesions showed a low likelihood of collapse. CONCLUSION: BS is useful for screening large ONK in patients with ONFH given that 89% of patients with ONFC who had a high risk of collapse of the knee were identified.

Adolescent↗
PubMed2003

Progressive collapse of transposed necrotic area after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head induces osteoarthritic change. Mid-term results of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head.

INTRODUCTION: Osteonecrosis of the femoral head is usually progressive, and once collapse of the femoral head develops, joint destruction almost invariably follows. Therefore, for partial osteonecrosis of the femoral head, various types of osteotomies have been developed in an attempt to save the femoral head and maintain the natural function of the hip joint. MATERIALS AND METHODS: We reviewed 25 hips in 21 patients for a mean follow-up period of 6.4 years after Sugioka's transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head. RESULTS: The clinical results were excellent or good in 20 hips (80%), and radiological success was observed in 15 hips (60%) with an absence of both collapse of the newly established weight-bearing area of the femoral head and narrowing of the joint space. Progressive collapse of the transposed necrotic area was noted in 10 hips (40%), and of these 10 hips, narrowing of the joint space was observed in 7 (70%) at follow-up. A significant correlation was demonstrated between progressive collapse of the transposed necrotic area and narrowing of the joint space. Growth of an osteophyte of the femoral head was observed postoperatively in 16 hips (64%), particularly at anterior and lateral sites of the femoral head. CONCLUSIONS: Though collapse of a new weight-bearing area can be prevented, progressive collapse of the transposed necrotic area induces anterior joint instability, giving rise to osteoarthritic change. It is therefore concluded that prevention of the collapse of the transposed necrotic area is important for satisfactory long-term results.

Adult↗
PubMed1987

Studies of nontraumatic osteonecrosis. The role of core decompression in the treatment of nontraumatic osteonecrosis of the femoral head.

This study reports a five-year experience with core decompression for treatment of nontraumatic osteonecrosis of the femoral head. There were 25 patients (39 hips) with predominantly steroid-associated osteonecrosis followed postoperatively for a minimum of two years. All patients were evaluated functionally, roentgenographically, histologically, and hemodynamically. At latest follow-up examination, two of 12 hips (17%) with Stage I disease, seven of 12 hips (58%) with Stage IIA disease, four of four hips with Stage IIB disease, and nine of 11 hips (82%) with Stage III disease have progressed roentgenographically and/or clinically. A lack of correlation between pressure manometrics, venography, and clinical outcome in this study suggests that mechanisms other than progressive ischemia may be involved. Current indications for core decompression are Ficat Stage 0, I, and IIA (sclerotic predominant) disease.

Adult↗
PubMed1983

[Osteonecrosis in retransplated kidney patients resuming hemodialysis. Comparison with a hemodialysed population not having undergone transplantation. Discussion of the role and duration of corticotherapy as cause of aseptic osteonecrosis].

A systematic study in 5 hemodialysis centres was carried out for the incidence of aseptic osteonecrosis (AON) after two patients presented with this condition during hemodialysis after transplantation and rapid "retransplantation". The following observations were made after the assessment of similar cases and a comparison with a control population of hemodialysis patients not having undergone attempted renal transplantation. Ten patients had undergone "retransplantation". Four of these patients had one or more sites of AON. In 2 cases steroid therapy had been of short duration (29 and 43 days) but at massive doses. In the other two cases, steroid therapy had been prolonged for over one year. On the other hand, no cases of AON were found in the 156 patients not having undergone attempted transplantation on chronic hemodialysis therapy of known duration (p less than 0,00002). This study suggests that steroid therapy of very short duration may lead to irreversible early osteomedullary ischemia and to osteonecrosis. There was no significant difference in the duration of hemodialysis between the two groups of patients, with and without AON.

Adrenal Cortex Hormones↗
PubMed2002

Osteonecrosis of the femoral head after solid organ transplantation: a prospective study.

BACKGROUND: The reported prevalence of osteonecrosis of the femoral head in patients who have undergone a solid organ transplant has ranged from 3% to 41%. The wide variation is due to the retrospective nature of most studies and the inability to capture data on asymptomatic patients. The primary goals of this study were to determine the true prevalence of osteonecrosis of the femoral head following solid organ transplantation, the time to the development of the osteonecrosis, and whether findings on magnetic resonance imaging precede the onset of symptoms. METHODS: Beginning in 1997, patients who had undergone a solid organ transplant were asked to participate in a prospective study in which they would be screened for osteonecrosis of the femoral head. Inclusion criteria included an age of greater than fourteen years, a first-time transplant, and magnetic resonance imaging performed within six months after the transplant. Exclusion criteria were pre-existing osteonecrosis of the femoral head in the hip included in the study, a history of inflammatory arthritis, previous hip surgery, any contraindication to magnetic resonance imaging, a prior organ transplant, prior systemic corticosteroid treatment, and mental health issues preventing adequate follow-up. Screening magnetic resonance imaging was performed every four months. Survivorship analysis was used to determine the prevalence of osteonecrosis of the femoral head. RESULTS: Fifty-two patients (103 hips) were enrolled in the study. Their ages ranged from twenty-four to sixty-five years (mean, forty-three years). Sixteen patients were dropped from the study, but the data collected on them before they were dropped were included in the analysis. Osteonecrosis of the femoral head was diagnosed in eight of the 103 hips. Survivorship analysis revealed that, at one year after the transplant, 89% +/- 7% of the hips and 80% +/- 13% of the patients were free of osteonecrosis of the femoral head; thus the prevalence of osteonecrosis one year after transplantation was 11% or 20%, respectively. The mean duration of follow-up of the remaining hips was 2.3 years. In two hips the osteonecrosis of the femoral head was seen on the initial screening magnetic resonance imaging, and in the other six it developed after the initial magnetic resonance imaging revealed negative findings. All cases of osteonecrosis of the femoral head developed within ten months after the transplant. Seven of the eight hips were asymptomatic at the time of diagnosis. There was a significant difference in the one-year osteonecrosis-free survival rate between the patients who were less than forty years old (78%) and those who were at least forty years old (97%) (p = 0.011). Diabetes, smoking, and rejection episodes were not risk factors for osteonecrosis of the femoral head. CONCLUSIONS: Our study of patients who had had a solid organ transplant revealed that the true prevalence of osteonecrosis of the femoral head in such patients is lower than that reported in most previous studies, osteonecrosis of the femoral head develops prior to the onset of symptoms, an age of less than forty years is a risk factor for osteonecrosis of the femoral head, and osteonecrosis of the femoral head develops within one year after transplantation. We recommend that magnetic resonance imaging be used to screen for osteonecrosis of the femoral head within one year after transplantation. The utility of additional magnetic resonance imaging after one year has not been established.

Adult↗
PubMed2006

Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee.

BACKGROUND: The reported outcomes of patients who underwent total or unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee are often from studies that lack the number of subjects necessary to generate meaningful conclusions. We systematically reviewed the available literature in order to define the outcomes of patients after total knee arthroplasty for secondary osteonecrosis and after total or unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee. METHODS: A literature review yielded twenty cohorts with demographic patient information and outcome scores (global knee scores, radiographic outcomes, and revision rates) for patients who had knee arthroplasty as treatment for either secondary or spontaneous osteonecrosis of the knee. The mean preoperative and postoperative global knee scores, the mean revision rate, and the categorization of the mean "poor" and mean "good" outcomes for the knees with each underlying disease were tabulated and reported. The demographic data and the reported mean global knee scores were weighted by the number of knees in each study. RESULTS: Total knee arthroplasty was performed in 150 knees with secondary osteonecrosis and 148 knees with spontaneous osteonecrosis, and unicompartmental knee arthroplasty was performed in sixty-four knees with spontaneous osteonecrosis. Total knee arthroplasty for spontaneous osteonecrosis of the knee was associated with the best outcomes (higher "good" and postoperative global knee scores and lower revision [3%] and "poor" outcome [6%] rates compared with the other two groups). The outcomes after total knee arthroplasty in knees with secondary osteonecrosis as well as in knees with spontaneous osteonecrosis were better in the cohorts operated on during or after 1985 than in those operated on before 1985. Similarly, the outcomes after unicompartmental knee arthroplasty in knees with spontaneous osteonecrosis of the knee were also better in the cohorts operated on during or after 1985 than in those operated on before 1985. CONCLUSIONS: Total knee arthroplasty performed as treatment for either secondary osteonecrosis or spontaneous osteonecrosis and unicompartmental knee arthroplasty performed as treatment for spontaneous osteonecrosis were associated with improved outcomes in cohorts with more recent operative dates. The evidence suggests that the use of contemporary cemented implants in total knee arthroplasty and the selective use of stems and augments in patients who have development of secondary osteonecrosis after total knee arthroplasty are producing outcomes that are comparable to those seen after total knee arthroplasty for osteoarthritis. Although the outcomes of patients who have total knee arthroplasty for the treatment of spontaneous osteonecrosis of the knee have historically been favorable, such outcomes have also shown particular improvement in the studies from more recent operative periods. Although poor outcomes were seen after unicompartmental knee arthroplasty in earlier studies of patients with spontaneous osteonecrosis of the knee, it is possible that those results were secondary to inappropriate patient selection, as the authors of the most recent and, to our knowledge, the only study to follow established operative indications regarding the use of unicompartmental knee arthroplasty reported excellent results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Adult↗
PubMed2002

Pathogenesis and natural history of osteonecrosis.

BACKGROUND AND OBJECTIVES: Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment. METHODS: A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited. RESULTS: Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one. CONCLUSIONS: Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis. RELEVANCE: A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options.

Adolescent↗
PubMed1994

Hypofibrinolysis: a common, major cause of osteonecrosis.

In 30 patients with osteonecrosis of the hip (12 idiopathic, 18 secondary), we assessed the role of hypofibrinolysis mediated by high levels of plasminogen activator inhibitor (PAI). We evaluated hypofibrinolysis as a common, potentially reversible, pathophysiologic cause of idiopathic osteonecrosis. In all 18 patients with secondary osteonecrosis, PAI was normal, as was the ability to activate fibrinolysis. Nine of the 12 patients with idiopathic osteonecrosis had exceptionally high PAI levels and could not normally elevate tissue plasminogen activator (tPA-Fx), the major stimulator of fibrinolysis, after 10 min of venous occlusion at 100 mm Hg. The group of 12 patients with idiopathic osteonecrosis, compared to the 18 with secondary osteonecrosis, had low mean stimulated tPA-Fx (1.92 vs. 7.6 IU/ml, P < or = .001) and very high stimulated PAI-Fx (70 vs. 7.6 U/ml, P < or = .01). Three of the 12 patients with idiopathic osteonecrosis had both normal PAI and normal stimulated tPA-Fx. These three patients and 14 of the 18 with secondary osteonecrosis had high lipoprotein (a) [Lp(a)] (> 20 mg/dl). Mean Lp(a) was much higher (60 mg/dl) in the patients with secondary osteonecrosis than Lp(a) (16 mg/dl, P < or = .001) in the 12 patients with idiopathic osteonecrosis. These findings suggest that hypofibrinolysis mediated by high PAI is a common cause of idiopathic osteonecrosis, whereas high Lp(a) may play an etiologic role in secondary osteonecrosis. Prospective studies of patients with high PAI and/or high Lp(a) should be carried out to assess further their apparently causal roles in osteonecrosis.

Adult↗
PubMed2005

Enoxaparin prevents progression of stages I and II osteonecrosis of the hip.

UNLABELLED: In a prospective pilot study, we hypothesized that enoxaparin (60 mg/day for 12 weeks) would prevent progression of Stages I and II osteonecrosis of the hip associated with thrombophilia or hypofibrinolysis or both over > or = 108 weeks of followup versus untreated historic controls, with different treatment responses in primary versus corticosteroid-associated secondary osteonecrosis. Patients with one or more thrombophilic-hypofibrinolytic disorder and Ficat Stages I or II osteonecrosis of at least one hip were included. A blinded committee interpreted anteroposterior and frog-leg lateral radiographs at entry in the study and every 36 weeks to > or = 108 weeks. Maintenance of the disease at Stages I and II versus progression of the osteonecrosis to Stages III and IV requiring total hip replacement was the major end point. Sixteen patients had primary osteonecrosis (25 hips; 13 Stage I, 12 Stage II), and 12 had secondary osteonecrosis (15 hips; five Stage I, 10 Stage II). With no Enoxaparin-related complications, 19 of 20 hips (95%) with primary osteonecrosis were unchanged from Stages I and II osteonecrosis at > or = 108 weeks; 12 of 15 hips (80%) with secondary osteonecrosis progressed to Stages III and IV osteonecrosis. In primary osteonecrosis at > or = 108 weeks, survival of 95% hips, or 76% (19/25 hips, based on intent to treat), compared favorably with untreated historical controls (approximately 20% 2-year survival), comparable to 20% survival in secondary hip osteonecrosis. Enoxaparin may prevent progression of primary hip osteonecrosis, decreasing the incidence of total hip replacement. LEVEL OF EVIDENCE: Therapeutic study, II-1 (prospective cohort study).

Arthroplasty, Replacement, Hip↗
PubMed2000

Osteonecrosis in HIV: a case-control study.

BACKGROUND: Osteonecrosis (avascular necrosis) has been infrequently reported in HIV-infected patients. It is not known whether HIV itself is an independent risk factor for osteonecrosis. METHODS: We identified 25 patients with osteonecrosis from 1984 to 1999 from a large county teaching hospital and two large practices in Dallas County that specialize in HIV-disease related therapy. A retrospective chart review was performed to evaluate potential risk factors for osteonecrosis. Each case was matched with two controls for HIV positive status and date of osteonecrosis diagnosis. RESULTS: In the study, 22 of 25 (88%) case patients had at least one osteonecrosis risk factor compared with 24 of 50 (48%) controls, p =.003. The most common osteonecrosis risk factors were hyperlipidemia (32%), alcoholism (28%), pancreatitis (16%), corticosteroids (12%), and hypercoaguability (12%). Of the cases, 12% were idiopathic. Multiple joints were involved in 72% of cases. Four of the case patients compared with none of the controls received megesterol acetate before the diagnosis of osteonecrosis, p =.01. No significant differences were found between cases and controls with respect to liver function tests, testosterone levels, triglyceride levels, cholesterol levels, or CD4 cell counts. Saquinavir was independently associated with osteonecrosis, p <.05. However, no differences in overall use of protease inhibitors among cases and controls were noted: 79% versus 76%, respectively. CONCLUSIONS: The increased incidence of osteonecrosis in HIV/AIDS may be due to an increased frequency of risk factors previously associated with osteonecrosis such as hyperlipidemia, corticosteroid use, alcohol abuse, and hypercoaguability. Use of protease inhibitors was not independently associated with osteonecrosis.

Adult↗
PubMed2006

Osteogenic gene expression decreases in stromal cells of patients with osteonecrosis.

Nontraumatic osteonecrosis is related to alcohol and glucocorticoid with unknown pathogenesis. Increased adipogenesis decreases bone morphogenetic protein 2 (BMP2) gene expression after glucocorticoid treatment. Lovastatin enhances BMP2 gene expression in rodents, reverses the effects of glucocorticoids on bone, and prevents glucocorticoid-induced osteonecrosis in chickens and humans. We hypothesized patients with osteonecrosis are more susceptible to glucocorticoid treatment than patients without osteonecrosis. Marrow stromal cell cultures from 14 patients with osteonecrosis, and 10 patients without osteonecrosis were treated with dexamethasone (0.1 micromol/L), lovastatin (1 micromol/L), or combined treatment. BMP2 and osteocalcin gene expression were evaluated by reverse-transcriptase polymerase chain reaction and real-time polymerase chain reaction. The suppression of BMP2 by dexamethasone was more pronounced and the enhancement by lovastatin was less pronounced in the osteonecrosis group. Dexamethasone suppressed osteocalcin in the osteonecrosis group. Among the subgroups of osteonecrosis, suppression of BMP2 and osteocalcin by dexamethasone occurred in glucocorticoid-induced osteonecrosis group. Our data suggest individuals who are more susceptible to a glucocorticoid-induced decreases in BMP2 and osteocalcin gene expression are more likely to have osteonecrosis, especially glucocorticoid-induced osteonecrosis.

Alcoholism↗
PubMed2000

Dysbaric osteonecrosis: a reassessment and hypothesis.

Dysbaric osteonecrosis is associated with exposure to large ambient pressure changes, and comprises necrotic lesions in the fatty marrow-containing shafts of the long bones, and the ball and socket joints (hips and shoulders). The fundamental causes are still in question and the illness remains a significant health hazard. Radiological and pathological features of both dysbaric and non-dysbaric osteonecrosis are indistinguishable and both are characterized by intramedullary venous stasis, ischemia and necrosis of bone. It has been generally accepted that gas bubbles (probably by initiating intramedullary venous stasis) are the prime cause of dysbaric osteonecrosis, as well as being responsible for Type 1 Decompression Sickness or 'the bends'. Importantly, however, not all series have found a correlation between dysbaric osteonecrosis and 'the bends'. Thus even though it is likely that gas bubbles remain the prime cause of dysbaric osteonecrosis, workers have proposed that in some cases there is another etiological factor which may exaggerate the pathologic effects of gas bubbles, making the bone more susceptible to necrosis. It is proposed that rapid compression by impeding venous drainage from bone initiates intramedullary venous stasis. In the presence of intramedullary gas bubbles, this may progress to thrombosis, ischemia and bone necrosis. The review offers an explanation for total sparing of the knee joint in dysbaric osteonecrosis, and sole involvement of the hip and shoulder (in terms of sub-articular lesions and subsequent joint collapse). In addition to continued observance of proper decompression procedures, a slower rate of compression may further reduce the incidence of dysbaric osteonecrosis. Bone death or osteonecrosis is a concept which Hippocrates put forward in antiquity (1), but it was not until 1794 that James Russell of Edinburgh wrote the first modern-day descriptions. In these cases infection was the predominant etiology (1,2). In 1888 Konig described necrosis of the adult femoral head without infection (3) (aseptic necrosis of bone) and in the same year Twynam reported a case of osteonecrosis in a caisson worker (4) in which there was still a significant infective component. In 1911 Bornstein and Plate, followed later and independently by Bassoe in 1913, presented radiological confirmation of aseptic necrosis of bone in compressed air workers (5). The first report of aseptic necrosis in an underwater diver subsequently appeared in 1936 (6). The condition of aseptic necrosis of bone in association with exposure to raised ambient pressure (previously referred to as caisson disease, pressure-induced osteoarthropathy (7), 'bone rot' (8) and other synonyms (6)) is now generally known as dysbaric osteonecrosis (6). Despite detailed examination of this problem by many authorities, dysbaric osteonecrosis still remains a significant occupational hazard with serious medico-legal consequences (5-13). This suggests that preventative measures are being based upon an incomplete understanding of the pathophysiology of the disease, and that other etiological factors are perhaps being overlooked.

Adult↗