Infection may play an important role in the pathogenesis of alveolar osteonecrosis following facial herpes zoster: a case report and literature review.

BACKGROUND: Herpes zoster (HZ) is one of the most common skin diseases caused by viruses. Facial HZ develops when the varicella-zoster virus affects the trigeminal nerve, and alveolar osteonecrosis is a rare complication. However, the exact pathogenesis of postherpetic alveolar osteonecrosis remains unclear. CASE DESCRIPTION: We encountered a patient who presented to the dermatology clinic with facial HZ and tooth exfoliation in the upper right jaw, and panoramic radiography revealed decreased bone density and poor alveolar socket healing in his right maxilla. Biopsy of the alveolar process revealed fragments of nonvital lamellar bone, which were devoid of osteoblasts and osteocytes and were surrounded by numerous neutrophils and bacterial aggregates. Thus, the diagnosis of alveolar osteonecrosis following facial HZ was confirmed. He then underwent resection of the osteonecrotic tissue. The pathological findings of postoperative tissue were similar to those of previous biopsies. Varicella-zoster virus and multiple types of bacteria were detected through next-generation sequencing, and the species of bacteria were consistent with the results of bacterial culture. Antibiotics and valaciclovir were administered during the perioperative period. The patient showed good recovery at the 9-month follow-up. CONCLUSIONS: The coexistence of bacterial and viral infection may play an important role in the pathogenesis of alveolar osteonecrosis following HZ. To our knowledge, we are the first to directly explore microbial pathogens in a case of postherpetic alveolar osteonecrosis through next-generation sequencing and bacterial culture. We recommend that oral examinations be carefully conducted for patients who are diagnosed with facial HZ, even if their facial rashes have faded away. We suggest that a prolonged and full-dose antiviral therapy course may be beneficial for the treatment of facial HZ with intraoral lesions. The implementation of dental preventive measures should be considered for patients with facial HZ. The application of antibiotics and excision of necrotic bone may reduce the abundance of bacteria in lesions and improve wound healing.

[Left mandibular osteonecrosis following herpes zoster of the third branch of left trigeminal nerve: A case report].

Herpes zoster of trigeminal nerve was a common skin disease caused by varicella-zoster virus infection. Simple involvement of the third branch of trigeminal nerve was rare, and so were oral complications such as pulpitis, periodontitis, spontaneous tooth loss, bone necrosis, etc. This article presented a case of herpes zoster on the third branch of the left trigeminal nerve complicated with left mandibular osteonecrosis. We reported the case of a 64-year-old man with sudden pain in the left half of the tongue 1 month ago, and then herpes on the left facial skin appeared following with acute pain.The local hospital diagnosed it as herpes zoster and treated it with external medication. A few days later, he developed gum pain in the left mandibular posterior tooth area. He was admitted to Peking University School and Hospital of Stomatology one week ago with loose and dislodged left posterior tooth accompanied by left mandibular bone surface exposure. Clinical examination showed bilateral symmetry and no obvious restriction of mouth opening. Visible herpes zoster pigmentation and scarring on the left side of the face appeared. The left mandibular posterior tooth was missing, the exposed bone surface was about 1.5 cm×0.8 cm, and the surrounding gingiva was red and swollen, painful under pressure, with no discharge of pus. The remaining teeth in the mouth were all Ⅲ degree loosened. Imageological examination showed irregular low-density destruction of the left mandible bone, unclear boundary, and severe resorption of alveolar bone. The patient was diagnosed as left mandibular osteonecrosis. Under general anesthesia, left mandibular lesion exploration and curettage + left mandibular partial resection + adjacent flap transfer repair were performed. The patient was re-exmained 6 months after surgery, there was no redness, swelling or other abnormality in the gums and the herpes pigmentation on the left face was significantly reduced. Unfortunately, the patient had complications of postherpetic neuralgia. This case indicate that clinicians should improve their awareness of jaw necrosis, a serious oral complication of trigeminal zoster, and provide early treatment. After the inflammation was initially controlled, surgical treatment could be considered to remove the necrotic bone, curettage the inflammatory granulation tissue, and extraction of the focal teeth to avoid further deterioration of the disease.

Osteonecrosis in patients with inflammatory bowel disease: a systematic review and meta-analysis.

BACKGROUND: The relationship of inflammatory bowel disease (IBD) with osteonecrosis or avascular necrosis (AVN) is uncertain. METHODS: Systematic review to estimate the frequency of osteonecrosis in IBD was performed. Electronic databases were searched on 12 December 2022 to identify relevant studies. We planned to estimate the pooled prevalence of AVN in IBD, the risk in IBD when compared to the healthy population (without any chronic disease), and the impact of steroid use on osteonecrosis (IBD with and without steroid use). The risk of Bias was assessed with the Joanna Briggs Institute appraisal tool. RESULTS: Fifteen studies including 105 154 individuals were included. The pooled rate AVN was 10.39 per 1000 patients (95% confidence interval, 4.44-24.11, I 2  = 97%). Subgroup analysis suggested that the prevalence was lower in larger studies (>1000 participants) at 3.10, 1.07; 8.98, I 2  = 98% versus 21.03, 8.69; 50.01, I 2  = 83%. The use of steroids did not seem to increase the risk of osteonecrosis in the included studies (pooled odds ratio: 1.88, 0.55-6.41, I 2  = 39%). The systematic review was limited by the absence of comparison with the control population free of chronic disease. CONCLUSION: IBD may be associated with a risk of osteonecrosis. Future studies should assess the risk in comparison to the healthy population and the impact of disease activity and IBD therapies on the risk.

[Infectious, pathologic humeral fracture in a patient with sickle cell disease-A rare case?] / Infizierte, pathologische Humerusfraktur bei Sichelzellanämie ­ noch ein Einzelfall?

The vaso-occlusive crises of sickle cell disease are accompanied by bone necrosis, which favors endogenous bacterial colonization and thus osteomyelitis. This poses a major challenge for eradication and fracture management.A 22-year-old patient with sickle cell disease sustained a multifragmentary, humeral shaft fracture. During surgical management, pus drained from the fracture site and further diagnostic work-up revealed osteomyelitis with evidence of Klebsiella aerogenes. Septicemia due to Klebsiella aerogenes had been treated 5 months prior to the accident, which occured because of a vaso-occlusive crisis. This is associated with clustered bone necrosis and endogenous germ colonization. Eradication of the germs and fracture care become a challenge. Repeated surgical procedures with segmental transfer can be a successful treatment option.

Minimal pre-operative leg length discrepancy as a risk factor of post-operative leg length discrepancy after total hip arthroplasty: a retrospective study of patients with non-traumatic osteonecrosis of the femoral head.

BACKGROUND: Leg length discrepancy (LLD) is one of the troublesome complications of total hip arthroplasty (THA). Previously, several risk factors have been suggested, but they were subjected to their inherent limitations. By controlling confounding variables, we hypothesized that known risk factors be re-evaluated and novel ones be discovered. This study aimed to analyze the independent risk factors for LLD after primary THA in patients with non-traumatic osteonecrosis of the femoral head (ONFH). METHODS: We retrospectively reviewed patients with non-traumatic ONFH who underwent unilateral THA between 2014 and 2021. All patients were operated by one senior surgeon using a single implant. Demographic data, surgical parameters, and radiological findings (pre-operative LLD, Dorr classification, and femoral neck resection) were analyzed to identify the risk factors of ≥ 5 mm post-operative LLD based on radiological measurement and to calculate odds ratios by logistic regression analysis. Post hoc power analysis demonstrated that the number of analyzed patients was sufficient with 80% power. RESULTS: One hundred and eighty-six patients were analyzed, including 96 females, with a mean age of 58.8 years at the time of initial THA. The average post-operative LLD was 1.2 ± 2.9 mm in the control group and 9.7 ± 3.2 mm in the LLD group, respectively. The LLD group tended to have minimal pre-operative LLD than the control group (-3.2 ± 5.1 mm vs. -7.9 ± 5.8 mm p = 2.38 × 10- 8). No significant difference was found between the groups in age, gender, body mass index, femoral cortical index, and implant size. CONCLUSION: Mild pre-operative LLD is associated with an increased risk of post-operative LLD after primary THA in patients with ONFH. Thus, surgeons should recognize pre-operative LLD to achieve an optimal outcome and must inform patients about the risk of developing LLD.

One-year unplanned readmission after total hip arthroplasty in patients with osteonecrosis of the femoral head: rate, causes, and risk factors.

BACKGROUND: The primary objectives of this study were to focus on one - year unplanned readmissions after THA in ONFH patients and to investigate rates, causes, and independent risk factors. METHODS: Between October 2014 and April 2019, eligible patients undergoing THA were enrolled and divided into unplanned readmission within one year and no readmission in this study. All unplanned readmissions within 1 year of discharge were reviewed for causes and the rate of unplanned readmissions was calculated. Demographic information, ONFH characteristics, and treatment-related variables of both groups were compared and analysed. RESULTS: Finally, 41 out of 876 patients experienced unplanned readmission. The readmission rate was 1.83% in 30 days 2.63% in 90 days, and 4.68% in 1 year. Prosthesis dislocation was always the most common cause at all time points studied within a year. The final logistic regression model revealed that higher risks of unplanned readmission were associated with age > 60 years (P = 0.001), urban residence (P = 0.001), ARCO stage IV (P = 0.025), and smoking (P = 0.033). CONCLUSIONS: We recommend the introduction of a strict smoking cessation program prior to surgery and the development of comprehensive management strategies, especially for the elderly and end-stage ONFH patients, and pay more attention to preventing prosthesis dislocation in the early days after surgery.

Effects of malnutrition on outcomes of patients with femoral head osteonecrosis undergoing total hip arthroplasty: A population-based study.

BACKGROUND: This study aimed to evaluate the impact of malnutrition on in-hospital outcomes in patients undergoing total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH). METHODS: This population-based retrospective study extracted data of patients undergoing THA for ONFH in the US National Inpatient Sample between 2005 and 2018. Factors associated with in-hospital mortality, medical and surgical complications, unfavorable discharge, and prolonged hospital stay were determined by logistic regression analysis. RESULTS: A total of 72,304 adults ≥18 years old with nontraumatic ONFH admitted for primary THA were included. Malnutrition was detected in 7152 (9.9%) patients using validated discharge codes. In-hospital mortality was 0.8% vs 0.1% for patients who were malnourished vs nonmalnourished. After adjusting for confounders, malnutrition was significantly associated with an increased risk of in-hospital death (adjusted odds ratio [aOR], 4.67; 95% CI, 2.43-8.97), medical complications (aOR, 1.49; 95% CI, 1.32-1.68), surgical complications (aOR, 1.78; 95% CI, 1.61-1.96), unfavorable discharge (aOR, 1.24; 95% CI, 1.11-1.39), and prolonged hospital stay (aOR, 1.90; 95% CI, 1.67-2.16) compared with adequate nutrition. Malnutrition was also associated with higher total hospital costs (adjusted ß = $9620; 95% CI, 7.87-11.36). Furthermore, the association between malnutrition, any medical or surgical complications, and unfavorable discharge was stronger in patients younger than 50 years than those ≥50 years old. CONCLUSIONS: In US patients undergoing primary THA for ONFH, malnutrition increases the risk of unfavorable in-hospital outcomes. This patient subgroup may require special attention and better strategies to improve perioperative care.

Talus dislocation and pereonal malleolar fracture after high-energy trauma: a case report.

Talus dislocation is a rare injury and it is usually the consequence of high energy traumas, despite the anatomical features of the talus which predispose to its dissociation (absence of muscle insertions with over 60% of the surface covered by cartilage). It may be associated with malleolar fractures. Standard treatment of closed talar dislocation is a controversial issue. The most common early complications is avascular necrosis. Authors report a case of a complete talar dislocation associated to displaced lateral malleolar fracture in a 18-years-old male following a high energy trauma treated by closed reduction and fixation of the malleolar fracture.

Osteonecrosis in Gaucher disease in the era of multiple therapies: Biomarker set for risk stratification from a tertiary referral center.

Background: A salutary effect of treatments for Gaucher disease (GD) has been a reduction in the incidence of avascular osteonecrosis (AVN). However, there are reports of AVN in patients receiving enzyme replacement therapy (ERT) , and it is not known whether it is related to individual treatments, GBA genotypes, phenotypes, biomarkers of residual disease activity, or anti-drug antibodies. Prompted by development of AVN in several patients receiving ERT, we aimed to delineate the determinants of AVN in patients receiving ERT or eliglustat substrate reduction therapy (SRT) during 20 years in a tertiary referral center. Methods: Longitudinal follow-ups of 155 GD patients between 2001 and 2021 were analyzed for episodes of AVN on therapy, type of therapy, GBA1 genotype, spleen status, biomarkers, and other disease indicators. We applied mixed-effects logistic model to delineate the independent correlates of AVN while receiving treatment. Results: The patients received cumulative 1382 years of treatment. There were 16 episodes of AVN in 14 patients, with two episodes, each occurring in two patients. Heteroallelic p.Asn409Ser GD1 patients were 10 times (95% CI, 1.5-67.2) more likely than p.Asn409Ser homozygous patients to develop osteonecrosis during treatment. History of AVN prior to treatment initiation was associated with 4.8-fold increased risk of AVN on treatment (95% CI, 1.5-15.2). The risk of AVN among patients receiving velaglucerase ERT was 4.68 times higher compared to patients receiving imiglucerase ERT (95% CI, 1.67-13). No patient receiving eliglustat SRT suffered AVN. There was a significant correlation between GlcSph levels and AVN. Together, these biomarkers reliably predicted risk of AVN during therapy (ROC AUC 0.894, p<0.001). Conclusions: There is a low, but significant risk of AVN in GD in the era of ERT/SRT. We found that increased risk of AVN was related to GBA genotype, history of AVN prior to treatment initiation, residual serum GlcSph level, and the type of ERT. No patient receiving SRT developed AVN. These findings exemplify a new approach to biomarker applications in a rare inborn error of metabolism to evaluate clinical outcomes in comprehensively followed patients and will aid identification of GD patients at higher risk of AVN who will benefit from closer monitoring and treatment optimization. Funding: LSD Training Fellowship from Sanofi to MB.

The incidence, risk factors, and outcomes of symptomatic avascular necrosis of bone among Chinese pediatric patients with acute lymphoblastic leukemia.

BACKGROUND: Avascular necrosis (AVN) of bone is a debilitating complication of pediatric patients with acute lymphoblastic leukemia (ALL). While it is extensively studied and reported in Western population, studies focused on Orientals are limited. This study aims to evaluate the incidence, risk factors, and clinical outcomes of AVN among Chinese children with ALL. METHODS: This study is a retrospective, territory-wide population-based cohort study of pediatric patients with ALL enrolled on one of the three consecutive ALL study protocols (ALL-IC-BFM 2002, CCLG-ALL 2008, and CCCG-ALL 2015). RESULTS: A total of 24 out of 533 pediatric subjects with ALL (4.5%) had symptomatic AVN. Age was the single most important risk factor associated with the development of AVN. Only three patients were below age of 10 at the time of diagnosis of ALL. The incidences of AVN in patients aged above and below 10 years were 18.2% ± 3.6% and 0.8% ± 0.5%, respectively, and were significantly different (p < 0.005). Treatment protocol, immunophenotype, and gender were not predictive of AVN. Among the 24 patients, five required orthopedic interventions in view of progressive and severe disease. For subjects with hip joints involvement, follow-up assessments showed 12 of 22 hip joints had radiological progression over a median duration of 3.63 years. Seventeen of them did not have pain at the latest follow-up and among patients with pain (n = 7), five did not experience any limitation on activities of daily living while two required use of walking aids or wheelchair. CONCLUSION: The incidence of symptomatic AVN in Chinese ALL patients was comparable to other studies in Western population. Adolescent age more than 10 years old was recognized to be the most important factor for development of AVN. Significant proportion of patients had radiological progression over time with a small percentage of subjects had daily activities affected.

Incidental osteonecrosis in the distal left femur in a case of beta-thalassemia with COVID-19: Role of [99mTc]Tc-MDP whole-body bone scan.

Secondary anemia in hemoglobinopathies like thalassemia can cause expansion of the bone marrow cavities because of compensatory marrow hyperplasia. This case demonstrates spontaneous osteonecrosis of the distal left femur in a patient with ß-thalassemia that may be secondary to ischemic infarction secondary to occlusion of the microvasculature within the expanded cancellous bone. This subject was referred to Hazrat Rasool Akram Hospital because of fever, cough, and bone pain. In the CT scan she had scattered peripheral CGO in both lungs due to COVID-19 with two paravertebral masses due to extramedullary hematopoiesis. The patient had also generalized bone pain so the physician asked for a whole-body bone scan and incidentally, we found a cold lesion with a rim of increased uptake in the distal left femur that with bone biopsy it was consistent with osteonecrosis. This case illustrates the importance of performing a whole-body bone scan in ß-thalassemia for the management of patients and diagnosis of occult osteonecrosis.

Osteonecrosis of the jaw associated with pembrolizumab.

We report a case of osteonecrosis of the jaw (ONJ) with pembrolizumab, a rare yet possibly emerging complication. In this case, a temporal relationship between the development of ONJ and the patient's treatment regimen suggested an association between pembrolizumab/GVD therapy and the development of ONJ. Thrombocytosis and anatomic factors may also have played a role. The number of patients using pembrolizumab will likely continue to increase. We document this instance in order to better inform dental treatment around cancer patients undergoing pembrolizumab therapy.

Mucormycosis causing oral and nasal osteonecrosis in a case of acute myeloid leukemia.

AIMS: Mucormycosis is a rare and aggressive fungal infection with a high mortality rate because of its rapidly progressive and destructive nature. The oral cavity is often affected under opportunistic conditions. We report a 34-year-old woman diagnosed with acute myeloid leukemia complained of slight swelling on the right side of her face with toothache and gingival swelling. An incisional biopsy was performed, and the specimen analysis revealed broad aseptate hyphae with a ribbon-like appearance, which is characteristic of opportunistic Mucorales infection. METHODS AND RESULTS: The oral lesion worsened, and invasion of the fungal infection into the maxillary sinus, nasal cavity, ethmoidal air cells, and sphenoid and frontal sinuses was observed. Partial maxillectomy was performed concomitantly with the ongoing chemotherapy for leukemia. A maxillofacial prosthesis was used for functional rehabilitation. CONCLUSION: Successful management requires a multimodal approach. In this case, the patient required different systemic approaches for treating leukemia and the fungal infection as well as rehabilitation with an obturator prosthesis.

Complete Femoral Osteonecrosis in the Setting of Myelodysplastic Syndrome.

ABSTRACT: A 76-year-old man was diagnosed with a hematological neoplasm combining myelodysplastic and myeloproliferative characteristics back in July 2021. Five months after the diagnosis, his condition got more severe when the blasts rose up to 14%, so he was started on hypomethylating agent-based therapy. A few weeks later, the patient was hospitalized after developing fever and a pain in the right thigh. To exclude any source of occult infection, an 18 F-FDG PET/CT was performed. FDG PET/CT showed a complete lack of metabolism in the right femur. An MRI and a biopsy confirmed the suspected diagnosis of osteonecrosis.

Familial Thrombophilia Is Associated With Primary Multifocal Osteonecrosis: A Case-Control Study of 40 Patients.

To characterize pathoetiologic associations of heritable thrombophilia-hypofibrinolysis with idiopathic (primary) multifocal osteonecrosis (ON) (≥3 ON anatomic sites), we prospectively studied 28 women and 12 men with primary multifocal ON compared with 27 women and 24 men with primary nonmultifocal ON (<3 sites) and 110 healthy controls without ON. The 40 cases with primary multifocal ON differed from controls for 3 familial thrombophilias: Factor V Leiden heterozygosity (6 of 40 [15%] vs 2 of 109 [2%], P=.002), G20210A prothrombin gene heterozygosity (6 of 40 [15%] vs 3 of 110 [3%], P=.011), and high (>150%) Factor VIII (8 of 40 [20%] vs 7 of 103 [7%], P=.031). These case-control familial coagulation differences paralleled those in 51 concurrently evaluated cases with primary nonmulti-focal ON, 7 of 51 (14%) of whom had Factor V Leiden heterozygosity vs 2% of controls (P=.005) and 14 of 44 (32%) of whom had high Factor VIII vs 7 of 103 (7%) of controls (P=.0002). Recognition of familial thrombophilia as a common pathoetiology of primary multifocal ON provides an opportunity for early anticoagulation (before joint collapse), allowing both prophylaxis and therapy aimed at relieving pain and slowing or stopping progression of the disease to joint collapse. [Orthopedics. 2023;46(3):164-168.].

Comparing the Radiologic and Functional Outcome of Radial Shortening Versus Capitate Shortening in Management of Kienböck's Disease.

BACKGROUND: Kienböck's disease is the avascular necrosis of the lunate bone. There is no consensus on the treatment strategy to avoid joint deterioration. This trial is conducted to compare the functional and radiological outcomes of radial shortening and capitate shortening techniques, in patients with avascular necrosis of lunate. METHODS: Patients with a confirmed diagnosis of Kienböck's disease who met the inclusion criteria were randomly divided into radial shortening and capitate shortening groups and treated by allocated technique. Physical examination and radiologic evaluations were performed before and 6 and 12 months after the operation. RESULTS: A total of 52 patients (52 wrists) of stage II or III Kienböck's disease were assessed for eligibility, 12 patients in the radial shortening group, and 17 patients remained until the end of the study. Patients in both groups achieved a satisfactory outcome, with no report of postoperative complications. None of the outcome measures, ranges of motion, grip, and pinch strengths were significantly different between the groups. The outcome was not considerably different in patients with positive or negative ulnar variances who were treated by capitate shortening technique. CONCLUSIONS: The capitate shortening technique which is performed through a smaller incision, and takes less time as compared with radial shortening can be advantageous for patients with stage II or III Kienböck's disease regardless of the ulnar variance. This method can be as effective as classical methods such as radial shortening in improving clinical and functional symptoms after surgery while causing fewer complications.

Osteonecrosis in Inflammatory Bowel Disease: Clinical Features, Risk Factor Analysis, and Outcomes.

BACKGROUND: Avascular necrosis (AVN) is a known adverse event associated with corticosteroid (CS) usage. Inflammatory bowel disease (IBD) is often treated with a CS for induction of remission. We sought to describe clinical features and outcomes of IBD patients with AVN. METHODS: In this retrospective, single-center, case-control study, patients with IBD who had a diagnosis of osteonecrosis, aseptic necrosis, or AVN from 1976 to 2009 were included, and each was matched with up to 2 controls (IBD but no AVN) on age, sex, IBD subtype, geographic area of residence, and date of IBD diagnosis. We abstracted risk factor data from the medical records. Conditional logistic regression was performed accounting for minor differences in age and date of first IBD visit to assess the relationship between putative risk factors and AVN, expressed as odds ratio and 95% confidence interval. RESULTS: Eighty-five patients were diagnosed with IBD-AVN and were matched with 163 controls. The mean age at AVN diagnosis was 47.5 years. AVN was diagnosed a median of 12.2 years after IBD diagnosis, and the control group was followed for a median of 15 years after IBD diagnosis to ensure that they did not have AVN. Ten percent of patients with AVN did not have any CS exposure. History of arthropathy or estrogen use in Crohn's disease and use of CS, osteoporosis, and history of arthropathy in ulcerative colitis were significantly associated with AVN. CONCLUSIONS: Most patients with IBD-AVN had multifocal involvement. Most had received CS, but many patients had other risk factors including arthropathy.

This single-center, case-control study of inflammatory bowel disease patients with osteonecrosis showed that while corticosteroid use was likely a risk factor, especially among ulcerative colitis patients, other risk factors included estrogen use among Crohn's disease patients, arthropathy, and osteoporosis.

Clinical Vignettes, Part II: Eyes, Teeth, and Bone.

Microvascular occlusions caused by sickle cell disease (SCD) can affect all ocular and orbital structures. Sickle cell retinopathy (SCR) is the most common ophthalmic manifestation of SCD. Fortunately, most individuals with SCR are visually asymptomatic. Vision loss in SCD most commonly occurs as a consequence of proliferative sickle cell retinopathy (PSR), in which pathologic retinal neovascularization occurs. To prevent significant vision loss and blindness, which can occur from complications of PSR, regular retinopathy surveillance screening examinations and consistent follow-up with a retina specialist are recommended. Scatter laser photocoagulation is the current gold-standard treatment to prevent vision threatening progression of PSR. Patients with sickle cell disease should have regular checkups with their dental care provider. Patients should be educated on the importance of proper dental care, a healthy diet, and the need for early intervention if they suspect any dental problems or are having dental pain. If any dental procedures that involve surgery or sedation are planned, it is critical to consult with the hematologist before the procedure is started. Prophylactic antibiotics may have to be prescribed before invasive dental procedures, such as extractions or periodontal surgery but is best determined by discussions between the dental care provider and the hematologist. Osteonecrosis is a highly prevalent skeletal complication of sickle cell disease that affects all genotypes. Risk factors for osteonecrosis include older age, HbSS genotype with concomitant alpha-thalassemia trait, frequent vaso-occlusive episodes, history of acute chest syndrome, elevated body mass index, and low white blood cell counts. Osteonecrosis causes progressive joint damage and associates with chronic pain, frequent acute care visits, and overall poor health-related quality of life. Current consensus guidelines recommend analgesics, physical therapy, and early consideration of joint arthroplasty in sickle cell-related osteonecrosis, although surgery may be deferred until late adolescence after growth plates have fused.

[A case of multiple osteonecrosis caused by acute-on-chronic pancreatitis].

A 61-year-old man was admitted due to alcoholic liver cirrhosis, portal vein thrombosis, hepatocellular carcinoma, and chronic pancreatitis. The patient's portal vein thrombosis improved with anticoagulant therapy. Serum amylase gradually increased, but there was no abdominal pain. The patient was placed under observation. The pain in both ankle and knee joints appeared on nine days after admission. Multiple osteonecrotic lesions of both elbows, both knees and both ankle joints were examined using 99mTc bone scintigraphic examinations. Magnetic resonance of the right ankle joint showed osteonecrosis. The pain of the right ankle joint improved with a decrease of serum amylase. We report that this is a rare case of multiple osteonecrosis caused by exacerbation of chronic pancreatitis.