Improving interface quality for 1-cm2 all-perovskite tandem solar cells.

All-perovskite tandem solar cells provide high power conversion efficiency at a low cost1-4. Rapid efficiency improvement in small-area (<0.1 cm2) tandem solar cells has been primarily driven by advances in low-bandgap (approximately 1.25 eV) perovskite bottom subcells5-7. However, unsolved issues remain for wide-bandgap (> 1.75 eV) perovskite top subcells8, which at present have large voltage and fill factor losses, particularly for large-area (>1 cm2) tandem solar cells. Here we develop a self-assembled monolayer of (4-(7H-dibenzo[c,g]carbazol-7-yl)butyl)phosphonic acid as a hole-selective layer for wide-bandgap perovskite solar cells, which facilitates subsequent growth of high-quality wide-bandgap perovskite over a large area with suppressed interfacial non-radiative recombination, enabling efficient hole extraction. By integrating (4-(7H-dibenzo[c,g]carbazol-7-yl)butyl)phosphonic acid in devices, we demonstrate a high open-circuit voltage (VOC) of 1.31 V in a 1.77-eV perovskite solar cell, corresponding to a very low VOC deficit of 0.46 V (with respect to the bandgap). With these wide-bandgap perovskite subcells, we report 27.0% (26.4% certified stabilized) monolithic all-perovskite tandem solar cells with an aperture area of 1.044 cm2. The certified tandem cell shows an outstanding combination of a high VOC of 2.12 V and a fill factor of 82.6%. Our demonstration of the large-area tandem solar cells with high certified efficiency is a key step towards scaling up all-perovskite tandem photovoltaic technology.

Conversion Total Hip Arthroplasty After Failed Pedicled Peri-Hip Bone Flap Grafting: The Chinese Experience.

BACKGROUND: This study investigated the perioperative outcomes of patients undergoing conversion total hip arthroplasty (THA) after failed peri-hip bone flap grafting (PBFG) and compared them with those patients undergoing primary THA for osteonecrosis of the femoral head (ONFH). METHODS: From January 2010 to December 2021, 163 Chinese patients (163 hips) were treated by conversion THA after failed PBFG (containing 94 patients who had pedicled vascularized iliac bone flap grafting and 69 patients who had pedicled vascularized greater trochanter bone flap grafting), and 178 Chinese patients were treated by primary THA. The preoperative baseline data and perioperative indicators in both groups were compared. RESULTS: In the conversion group, patients had significantly greater blood loss, a longer length of stay, and greater changes in serum hemoglobin than those in the primary THA group (P < 0.05). The operative room time, transfusion volume, calculated blood loss, changes in serum hematocrit, and increased superficial infection (P > 0.05) in the conversion group were greater compared with the primary cohort; however, the difference was not statistically significant. The mean postoperative Harris Hip Scoring System (HHS) of the PBFG group at the one-month follow-up was 81, and the control group had an 82 score. Importantly, subgroup analysis of the PBFG group indicated that there was no significant difference between patients who had prior pedicled vascularized iliac bone flap grafting and pedicled vascularized greater trochanter bone flap grafting (P > 0.05), except for the operative room time (P = 0.032). CONCLUSION: Hip-sparing surgery of ONFH did not make THA more difficult or lead to more peri-operative complications, but increased blood loss and extended hospital stay from a prior PBFG are still notable problems in clinical practice. Thus, it is necessary for surgeons to focus attention on the improvement of the preoperative condition and prepare for any specific intraoperative challenges.

Bone marrow mesenchymal stem cells paracrine TGF-ß1 to mediate the biological activity of osteoblasts in bone repair.

BACKGROUND: Bone marrow mesenchymal stem cells (BMSCs) are an important source of seed cells for regenerative medicine and tissue engineering therapy. BMSCs have multiple differentiation potentials and can release paracrine factors to facilitate tissue repair. Although the role of the osteogenic differentiation of BMSCs has been fully confirmed, the function and mechanism of BMSC paracrine factors in bone repair are still largely unclear. This study aimed to determine the roles of transforming growth factor beta-1 (TGF-ß1) produced by BMSCs in bone tissue repair. METHODS: To confirm our hypothesis, we used a Transwell system to coculture hBMSCs and human osteoblast-like cells without contact, which could not only avoid the interference of the osteogenic differentiation of hBMSCs but also establish the cell-cell relationship between hBMSCs and human osteoblast-like cells and provide stable paracrine substances. In the transwell coculture system, alkaline phosphatase activity, mineralized nodule formation, cell migration and chemotaxis analysis assays were conducted. RESULTS: Osteogenesis, migration and chemotaxis of osteoblast-like cells were regulated by BMSCs in a paracrine manner via the upregulation of osteogenic and migration-associated genes. A TGF-ß receptor I inhibitor (LY3200882) significantly antagonized BMSC-induced biological activity and related gene expression in osteoblast-like cells. Interestingly, coculture with osteoblast-like cells significantly increased the production of TGF-ß1 by BMSCs, and there was potential intercellular communication between BMSCs and osteoblast-like cells. CONCLUSIONS: Our findings provide evidence that the biological mechanism of BMSC-produced TGF-ß1 promotes bone regeneration and repair, providing a theoretical basis and new directions for the application of BMSC transplantation in the treatment of osteonecrosis and bone injury.

[Research status and development of biodegradable zinc alloy as orthopedics implant].

Znic (Zn) alloys with good cytocompatibility and suitable degradation rate have been a kind of biodegradable metal with great potential for clinical applications. This paper summarizes the biological role of degradable Zn alloy as bone implant materials, discusses the mechanical properties of different Zn alloys and their advantages and disadvantages as bone implant materials, and analyzes the influence of different processing strategies (such as alloying and additive manufacturing) on the mechanical properties of Zn alloys. This paper provides systematic design approaches for biodegradable Zn alloys as bone implant materials in terms of the material selection, product processing, structural topology optimization, and assesses their application prospects with a view to better serve the clinic.

Mechanistic Understanding of Oxidation of Tin-based Perovskite Solar Cells and Mitigation Strategies.

Tin (Sn)-based perovskites as the most promising absorber materials for lead-free perovskite solar cells (PSCs) have achieved the record efficiency of over 14 %. Although suppressing the oxidation of Sn-based perovskites is a frequently concerned topic for Sn-based PSCs, many studies have given vague explanations and the mechanisms are still under debate. This is in principal due to the lack of an in-depth understanding of various and complex intrinsic and extrinsic factors causing the oxidation process. In this context, we critically review the chemical mechanism of facile oxidation of Sn-based perovskites and differentiate its detrimental effects at material- and device-level. More importantly, we classify and introduce the intrinsic factors (raw materials and solvent of perovskite precursors) and extrinsic factors (exposure to neutral oxygen and superoxide) causing the oxidation with their corresponding anti-oxidation improvement methods. The presented comprehensive understanding and prospect of the oxidation provide insightful guidance for suppressing the oxidation in Sn-based PSCs "from the beginning to the end".

Manipulation of the Buried Interface for Robust Formamidinium-based Sn-Pb Perovskite Solar Cells with NiOx Hole-Transport Layers.

Low band gap tin-lead perovskite solar cells (Sn-Pb PSCs) are expected to achieve higher efficiencies than Pb-PSCs and regarded as key components of tandem PSCs. However, the realization of high efficiency is challenged by the instability of Sn2+ and the imperfections at the charge transfer interfaces. Here, we demonstrate an efficient ideal band gap formamidinium (FA)-based Sn-Pb (FAPb0.5 Sn0.5 I3 ) PSC, by manipulating the buried NiOx /perovskite interface with 4-hydroxyphenethyl ammonium halide (OH-PEAX, X=Cl- , Br- , or I- ) interlayer, which exhibits fascinating functions of reducing the surface defects of the NiOx hole transport layer (HTL), enhancing the perovskite film quality, and improving both the energy level matching and physical contact at the interface. The effects of different halide anions have been elaborated and a 20.53 % efficiency is obtained with OH-PEABr, which is the highest one for FA-based Sn-Pb PSCs using NiOx HTLs. Moreover, the device stability is also boosted.

High-harmonic generation in polycrystalline CdTe nano-films via macroscopic investigations.

Bright high harmonics generation (HHG) in CMOS-compatible nano-films can provide new opportunities for integrated coherent ultra-violet sources and attosecond photonic devices. Up to now, most HHG studies have been limited to single crystals. Polycrystalline materials, which consist of many grains separated by grain boundaries and normally have random crystallographic orientations, have rarely been explored for HHG. Understanding and predicting the HHG properties in polycrystalline nano-films are important owing to its merits of low cost and diversified properties, but challenging due to their complicated electronic structures. Here, we for the first time experimentally discover the correspondence between HHG in polycrystalline matters and macroscopic material parameters, to the best of our knowledge. Pumped by a mid-infrared femtosecond laser centered at 7.1 µm wavelength, bright and long-term stable harmonics extending to 25th orders (284 nm) are demonstrated in polycrystalline cadmium telluride (CdTe) nano-films. It is found that the HHG strengths in the transmission and the reflection behave differently as a function of the material thickness in the range from 6 nm to 4 µm, which is highly correlated to the measured macroscopic conductivity. The experimental findings agree well with the recent theoretical prediction [Phys. Rev. B103(15), 155426 (2021)10.1103/PhysRevB.103.155426]. This work provides a simple gauge to study and predict HHG in complicated polycrystalline and amorphous nano-systems, and paves the way for novel strong-field nanophotonics based on polycrystalline nano-films.

Vortex evolution patterns for flow of dilute polymer solutions in confined microfluidic cavities.

Flow instability in confined cavities has attracted extensive interest due to its significance in many natural and engineering processes. It also has applications in microfluidic devices for biomedical applications including flow mixing, nanoparticle synthesis, and cell manipulation. The recirculating vortex that characterizes the flow instability is regulated by the fluid rheological properties, cavity geometrical characteristics, and flow conditions, but there is a lack of quantitative understanding of how the vortex evolves as these factors change. Herein, we experimentally study the flow of dilute polymer solutions in confined microfluidic cavities and focus on a quantitative characterization of the vortex evolution. Three typical patterns of vortex evolution are identified in the cavity flow of dilute polymer solutions over a wide range of flow conditions. The geometrical characteristics of the cavity are found to have little effect on the patterns of vortex evolution. The geometry-independent patterns of vortex evolution provide us an intuitive paradigm, from which the interaction and competition among inertial, elastic and shear-thinning effects in these cavity-induced flow instabilities are clarified. These results extend our understanding of the flow instability of complex fluids in confined cavities, and provide useful guidelines for the design of cavity-structured microfluidic devices and their applications.

Organic enantiomeric high-Tc ferroelectrics.

For nearly 100 y, homochiral ferroelectrics were basically multicomponent simple organic amine salts and metal coordination compounds. Single-component homochiral organic ferroelectric crystals with high-Curie temperature (Tc) phase transition were very rarely reported, although the first ferroelectric Rochelle salt discovered in 1920 is a homochiral metal coordination compound. Here, we report a pair of single-component organic enantiomorphic ferroelectrics, (R)-3-quinuclidinol and (S)-3-quinuclidinol, as well as the racemic mixture (Rac)-3-quinuclidinol. The homochiral (R)- and (S)-3-quinuclidinol crystallize in the enantiomorphic-polar point group 6 (C6) at room temperature, showing mirror-image relationships in vibrational circular dichroism spectra and crystal structure. Both enantiomers exhibit 622F6-type ferroelectric phase transition with as high as 400 K [above that of BaTiO3 (Tc = 381 K)], showing very similar ferroelectricity and related properties, including sharp step-like dielectric anomaly from 5 to 17, high saturation polarization (7 µC/cm2), low coercive field (15 kV/cm), and identical ferroelectric domains. Their racemic mixture (Rac)-3-quinuclidinol, however, adopts a centrosymmetric point group 2/m (C2h), undergoing a nonferroelectric high-temperature phase transition. This finding reveals the enormous benefits of homochirality in designing high-Tc ferroelectrics, and sheds light on exploring homochiral ferroelectrics with great application.

Tranexamic versus aminocaproic acids in patients with total hip arthroplasty: a retrospective study.

BACKGROUND: Recently, tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) have been applied in total hip arthroplasty (THA). However, doubts in clinicians' minds about which medicine is more efficient and economical in THA need to be clarified. Therefore, this study compared the efficacy and cost of the intraoperative administration of TXA and EACA per surgery in decreasing perioperative blood transfusion rates in THA. METHODS:  This study enrolled patients who underwent THA between January 2019 to December 2020. A total of 295 patients were retrospectively divided to receive topical combined with intravenous TXA (n = 94), EACA (n = 97) or control (n = 104). The primary endpoints included transfusions, estimated perioperative blood loss, cost per patient and the drop in the haemoglobin and haematocrit levels. RESULTS: Patients who received EACA had greater total blood loss, blood transfusion rates, changes in HGB levels and mean cost of blood transfusion per patient (P < 0.05) compared with patients who received TXA. In addition, both TXA and EACA groups had significantly fewer perioperative blood loss, blood transfusion, operation time and changes in haemoglobin and haematocrit levels than the control group (P < 0.05). Cost savings in the TXA and EACA groups were 736.00 RMB and 408.00 RMB per patient, respectively. CONCLUSIONS: The application of perioperative antifibrinolytics notably reduces the need for perioperative blood transfusions. What's more, this study demonstrated that TXA is superior to EACA for decreasing blood loss and transfusion rates while at a lower cost per surgery. These results indicate that TXA may be the optimum antifibrinolytics for THA in Chinese area rather than EACA.

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study.

BACKGROUND: The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications. METHODS: In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH. RESULTS: In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10-5). CONCLUSION: This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH. LEVEL OF EVIDENCE: Level III, diagnostic study.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment.

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

Clinical Application of the Musculoperiosteal Iliac Flap for Osteonecrosis of the Femoral Head.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) often affects young, active patients, and the femoral head's preservation is the primary goal of treatment for this disease. Vascularized iliac crest bone grafting is one of the many vascularized procedures used in treating ONHF. In some cases, we selectively performed this procedure using the musculoperiosteal iliac flap with the ascending branch of the lateral femoral circumflex artery for ONFH treatment. METHODS: Twelve patients (12 hips) with nontraumatic femoral head necrosis underwent musculoperiosteal iliac flap transfer with the ascending branch of the lateral femoral circumflex artery. The Harris Hip Score (HHS), visual analog scale score, and double-hip X-ray findings were used to analyze hip function changes within 10 days preoperatively and 6 and 12 months postoperatively. RESULTS: The mean HHS increased from 52.33 ± 3.34 preoperatively to 65.92 ± 5.04 6 months postoperatively and 79.75 ± 3.84 12 months postoperatively, and the data showed a statistical significance difference between preoperative and postoperative (F = 131.90, P < 0.01). The HHS at 6 and 12 months after surgery were significantly different (P < 0.01). The visual analog scale score showed the same trend. The x-ray of hip joints at 6 and 12 months after surgery showed that the femoral heads' shape and contour were good, femoral heads did not collapse, and the transferred bone flaps healed well. CONCLUSIONS: Musculoperiosteal iliac flap transfer with the ascending branch of the lateral femoral circumflex artery may be an effective method with a high clinical success rate for treating young patients with early to midstage ONFH.

Diagnosis and Treatment of Femoral Head Osteonecrosis: A Protocol for Development of Evidence-Based Clinical Practice Guidelines.

INTRODUCTION: There are many treatment options for patients who have osteonecrosis of the femoral head (ONFH) and management strategies vary widely both among and within individual countries. Although many researchers have attempted to elucidate the optimal strategies for managing this disease, the lack of large-scale randomized control trials and the lack of agreement on disease staging have curtailed the development of clear-cut guidelines. MATERIALS AND METHODS: The Association Research Circulation Osseous (ARCO) group sought to address three questions for the management of patients who have ONFH: 1) What imaging studies are most sensitive and specific for the diagnostic evaluation of patients who have ONFH?; 2) What is the best treatment strategy for preventing disease progression in patients who have pre-collapse lesions?; and 3) What is the best treatment strategy for patients who have post-collapse disease? The Patient, Intervention, Comparison, and Outcome (PICO) format was used to formulate the search strategy for each research question. A systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ARCO participants have been allocated to three groups, each representing one of the PICO questions. After qualitative and quantitative analysis of the data extracted from studies pertaining to each of the three research questions, a set of evidence-based clinical practice guidelines will be proposed for the management of patients who have ONFH. DISCUSSION: It is not always clear which treatment method is optimal for the management of ONFH. Thus, many surgeons have developed and performed various procedures based on patient-specific factors. As there is no consensus on the optimal treatment for various stages of disease, it was clear that developing evidence-based clinical practice guidelines would provide more structure and uniformity to management of these patients. Therefore, the results of this systematic review will lead to the development guidelines that may improve patient-care strategies and result in better outcomes for patients who have ONFH.

Differential lung inflammation and injury with tobacco smoke exposure in Wistar Kyoto and spontaneously hypertensive rats.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and has been associated with periods of intense lung inflammation. The objective of this study was to characterize whether similar rat strains, possessing different genetic predispositions, might play a role in exacerbating the pathophysiology of COPD-like cellular and structural changes with progressive 12-week exposure to tobacco smoke (TS). Normotensive Wistar Kyoto (WKY) and spontaneously hypertensive (SH) rats were compared. MATERIALS AND METHODS: WKY and SH rats were exposed to filtered air or to tobacco smoke at a particulate concentration of 80 mg/m3 for 4, 8, or 12 weeks. Necropsy was performed 24 h after the last exposure to obtain cells by bronchoalveolar lavage for total cell and differential counts. Scoring of lung tissues and immunohistochemical staining for M1 (pro-inflammatory) and M2 (anti-inflammatory) macrophages were performed on paraffin-embedded lung sections. RESULTS AND DISCUSSION: With progressive exposure, TS-exposed SH rats demonstrated significant airspace enlargement, mucin production, and lung inflammation compared to their FA control and TS-matched WKY rats. Moreover, SH rats also demonstrated increased expression of the M1 marker in alveolar macrophages compared to FA control, as well as the M2 marker compared to controls and TS-exposed WKY rats. CONCLUSION: The progressive tobacco smoke exposure contributes to persistent lung injury and inflammation that can be significantly enhanced by rat strain susceptibility in the genesis of COPD.

Proper mechanical stress promotes femoral head recovery from steroid-induced osteonecrosis in rats through the OPG/RANK/RANKL system.

BACKGROUND: Long-term use of steroid may lead to osteonecrosis of the femoral head (ONFH). Mechanical stress may help bone formation and remodeling. This study aimed to probe the role of mechanical stress in the femoral head recovery in rats. METHODS: Rat models with ONFH were induced by steroid. Rats were subjected to different levels of mechanical stress (weight-bearing training), and then the morphology and bone density of femoral head of rats were measured. The mRNA and protein levels of the OPG/RANK/RANKL axis in rat femoral head were assessed. Gain- and loss-of function experiments of OPG were performed to identify its role in femoral head recovery following stress implement. The ex vivo cells were extracted and the effects of stress and OPG on osteogenesis in vitro were explored. RESULTS: Steroid-induced ONFH rats showed decreased bone density and increased bone spaces, as well as necrotic cell colonies and many cavities in the cortical bones and trabeculars. Proper mechanical stress or upregulation of OPG led to decreased RANK/RANKL expression and promoted femoral head recovery from steroid-induced osteonecrosis. However, excessive mechanical stress might impose too much load on the femurs thus leading even retard femoral head recovery process. In addition, the in vitro experimental results supported that proper stress and overexpression of OPG increased the osteogenesis of ex vivo cells of femoral head. CONCLUSION: This study provided evidence that proper mechanical stress promoted femoral head recovery from steroid-induced osteonecrosis through the OPG/RANK/RANKL system, while overload might inhibit the recovery process. This study may offer novel insights for ONFH treatment.

Clinical Follow-up Study of the Reconstruction of the Femoral Head With Transferred Vascularized Greater Trochanter Bone Graft for Association Research Circulation Osseous III-IV Osteonecrosis of the Femoral Head.

PURPOSE: The aim of the study was to investigate the curative efficacy of osteonecrosis of the femoral head (ONFH) in a hip-preserving operative approach, by transferring a vascularized greater trochanter graft combined with osteotomy of the upper third of femoral head, in an attempt to seek an innovative approach for patients who experienced middle- to late-stage ONFH with femoral head's weight-bearing area severely collapsed. METHOD: Our research included a total of 23 patients (23 hips) who accepted hip-preserving surgery by reconstructing the femoral head with transferred vascularized greater trochanter bone graft for ONFH from January 2013 to December 2017. The definition of reconstructing the femoral head is that we do the osteotomy on the upper third of the femoral head with weight-bearing area severely collapsed, and the remnant femoral head requires a hemispherical bone graft to recover the shape. A vascularized greater trochanter bone graft was next transferred and fixed at the upper portion of the remnant femoral head, and then, the shape and vascular supply of the femoral head are successfully reconstructed. The clinical assessment was performed with Harris Hip Score system. Kaplan-Meier survival curves with femoral head collapse as the end point showing the probability of progression in collapsed femoral head based on the gender, age and body mass index. RESULTS: Twenty-three patients (23 hips) were eventually contacted by telephone for an outpatient clinic follow-up, with a mean follow-up time of 41.35 months (varied from 16 to 72 months), no patients lost contact. Seven patients (7 hips) had radiographic stage progress. One patient (1 hip) had conversion to total hip arthroplasty at 24 months postoperatively because of progressive femoral head collapse and severely pain. The image success rate was 69.6%, clinical success rate was 65.2%, and the clinical survival rate was 96%. The average Harris Hip Score was 82.5 ± 5.5 points at the last follow-up, representing a great improvement compared with the 51.9 ± 7.2 points obtained preoperatively (P<0.05). Kaplan-Meier survival curves with femoral head collapsed as the end point showing the probability of progression in collapsed femoral head based on the sex, age, and body mass index. CONCLUSIONS: Reconstructing the femoral head with transferred vascularized greater trochanter bone graft provides a new method for the treatment of the young Association Research Circulation Osseous stage III-IV ONFH patients with severely femoral head collapsed, which can better improve the patient's symptoms, the quality of life, and delay the age of undergoing arthroplasty in young patients.

Digital Subtraction Angiography and Magnetic Resonance Imaging-Based Staging of Circulatory Obstruction in the Femoral Head During Osteonecrosis of the Femoral Head Development.

INTRODUCTION: Nontraumatic osteonecrosis of the femoral head (NONFH) is a common and difficult disease in orthopedics. Magnetic resonance imaging (MRI) assessment of NONFH and bone marrow edema was combined with digital subtraction angiography (DSA) to evaluate the circulatory status of NONFH in different Association Research Circulation Osseous stages. Based on the circulatory obstruction status (venous stasis, arterial ischemia, and arterial occlusion), appropriate perioperative management was adopted to achieve hip joint preservation and effectively delay the time for total hip arthroplasty in young patients. METHODS: From January 2013 to March 2019, 41 orthopedic patients were evaluated for medical imaging. Sixty-one ONFH cases were enrolled. The inclusion criteria include: (1) Clear diagnosis of osteonecrosis of the femoral head. (2) No history of infection in the affected hip, no history of hip surgery, and no congenital hip diseases. The patients enrolled in this study were 8 women and 33 men between the ages of 19 and 64 years (mean, 39.25 ± 8.90 years). Preoperative X-ray, computed tomography, MRI, DSA, and histological data were taken. RESULTS: The combination of DSA and MRI can efficiently show blood supply changes in the femoral head of NONFH patients at different Association Research Circulation Osseous stages; and also can possibly reveal the causes and development of NONFH. Different stages of circulatory obstruction of the femoral head can be clearly distinguished and used to determine the required perioperative management, thus yielding successful surgical outcomes. CONCLUSIONS: The existing classification systems do not fully reflect the progression of circulatory obstruction in ONFH. Each stage of NONFH development has its own characteristics circulatory obstruction. Early-stage NONFH displays characteristic venous stasis of the femoral head, whereas advanced stage NONFH is characterized by insufficient arterial blood supply to the femoral head. Corresponding NONFH treatment strategies should be considered based on their specific circulatory status. This work also provides guidance and recommendations for adopting corresponding femoral head preserving strategies for young patients in different NONFH circulatory status.

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head.

BACKGROUND: The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. METHODS: In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. RESULTS: Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I-X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II-X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III-fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV-X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. CONCLUSION: A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.