Sclerotic bone: a sign of bone reaction in patients with medication related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction associated with antiresorptive drugs such as bisphosphonates and denosumab. When dealing with advanced and/or multiple MRONJ lesions undergoing surgical therapy, the extent of surgery is often a topic of discussion. The aim of this study was to identify the differences in bone density in and around the MRONJ lesion before and after surgical treatment to evaluate the needed surgical extend of the modelling osteotomy. In this retrospective study 26 patients with MRONJ lesions that were surgically treated in our department were observed. Length, width and bone density were measured in panoramic radiograph pre and postoperatively with the Imaging processing software Sidexis and ImageJ (Fiji). The necrotic area, the surrounding sclerotic area as well as the healthy contralateral side were observed. Measurements were performed by two independent observers. Pearson correlation was calculated to determine the interobserver variability. Bone density was significantly reduced in the necrotic bone area compared to the healthy unaffected contralateral reference side. The sclerotic bone area surrounding the necrosis showed increased bone density compared to the contralateral unaffected reference side. The density of the sclerotic bone area was increased in the previously affected MRONJ area in the postoperative panoramic radiograph. The pre and postoperative density showed no significant correlation to healing behaviour. The focus of the modelling osteotomy in surgical treatment of mature MRONJ lesions should be predominantly on the parts that appear necrotic and less dense in the panoramic radiograph as sclerotic areas might be an expression of bone reaction.

Osteonecrosis of the Knee: The Unintended Consequence of Steroid Abuse.

The anti-inflammatory and immunosuppressive properties of steroids allow their use in a wide variety of rheumatological diseases, asthma, inflammatory bowel disease, cancer therapy, and severe viral infections. Though life-saving or organ-saving, long-term clinical use leads to a vast array of complications. Osteoporosis is the most common orthopedic side effect of steroid abuse, while osteonecrosis is a rare occurrence. The risk of osteonecrosis appears to be dose and duration dependent, but several patient factors also play a major role and usually affect the femoral head followed by the knee joint. The long-term effects of steroids must be explained to all patients on therapy, but this risk is missed in individuals who abuse steroids for recreational or performance-enhancing purposes. We describe a male, aged 29 years, who presented with dull aching bilateral knee pain of 2-years' duration after a long-term steroid abuse for weight and muscle mass gain. Radiological and magnetic resonance imaging studies confirmed osteonecrosis of femoral and tibial condyles and secondary degenerative arthritis of the knee joint. Prompt suspicion, early diagnosis, and intervention in osteonecrosis of knee joints, and termination of steroids may reverse the pathology and prevent progression of disease.

Is There a Correlation between the Radiological and Clinical Outcome after Core Decompression of the Radius for Kienböck Disease?

Background: Despite the good clinical results in the treatment of Kienböck disease with distal radius core decompression, a radiological progression to a certain degree in the long-term follow-up is possible. Is there a negative correlation between the clinical improvement of the patients and the radiological progression? Methods: We retrospectively reviewed the radiological and clinical results of 24 patients (mean age: 38 years; 10 women) treated with core decompression for Kienböck disease. The mean follow-up was 10 years. Results: A radiologic progression in the Lichtman classification was seen in nine patients. The Spearman correlation did not show any correlation between this radiological progression and the clinical outcome. Namely -0.06 between Mayo and Lichtman classification and 0.16 between VAS and Lichtman classification. Conclusions: We found that the clinical outcomes do not deteriorate despite a radiological progression of patients treated with core decompression for Kienböck disease Level of Evidence: Level IV (Therapeutic).

Clinical outcomes in patients with scaphoid non-union treated with the vascularized medial femoral condyle technique a case series.

INTRODUCTION: Non-union is a prevalent complication of scaphoid fractures. Late diagnosis is common and has a clinical impact due to functional limitations for the patient. Multiple treatments have been proposed to manage this complication, ranging from conservative (i.e., orthopedic) to surgical treatment. The vascularized medial femoral condyle technique has shown satisfactory clinical and paraclinical results, mainly in presence of avascular necrosis of the proximal pole but data regarding functional outcomes and patient satisfaction is scarce. This case series aims to describe the clinical and patient-reported outcomes in a consecutive series of patients with non-union of the proximal third of the scaphoid treated with vascularized medial femoral condyle technique. METHODS: Case series reporting results for a consecutive - initial cohort of patients who presented with a non united fracture of the proximal pole of the scaphoid, avascular necrosis of the proximal pole was documented by CT od MRI imaging preoperatively in all patients. Measurement instruments include the q-DASH and PRWE questionnaires, radiographic images, goniometry, and assessment of grip strength. RESULTS: Twelve consecutive patients are included and they represent the initial cases for all surgeons involved; bone union was obtained in 10 patients (83%) after a mean follow-up time of 31 months (6-72), successful improvement in the range of motion and grip strength was documented. A high rate of satisfaction expressed by the patient was obtained, with an average score in Q-DASH of 17.3 and 20.1 in PRWE. CONCLUSIONS: The vascularized medial condyle technique in cases of nonunion of scaphoid fracture is a reproducible treatment in clinical terms, both in imaging and functional terms, and in patient satisfaction. The learning curve is flat for a dedicated multi surgeon team.

Postoperative scaphoid alignment, smoking, and avascular necrosis mostly influence union rate after scaphoid reconstruction: Results from a retrospective single center study involving 370 patients.

Current literature does not definitely demonstrate the superiority of any particular scaphoid reconstruction method. The primary goal of this retrospective single center study was to evaluate the influence of reconstruction techniques and other factors on the union rate after reconstruction of scaphoid nonunions. In the study, 370 patients with nonunions classified as stable (Mayo 1) or unstable (Mayo 2) depending on carpal alignment were included. Minimal radiological follow-up was 3 months. Bone healing after scaphoid reconstruction was evaluated using computer tomography scans in 294 and radiograms in 76 patients. Univariate and multivariate logistic regressions were applied in the analysis. Eight statistically significant factors that influenced the union rate were fixation method, type of previous operations, number of all operations, number of reconstructions, smoking, postoperative pathological lateral intrascaphoid angle (LISA>45°), avascular necrosis (AVN), and stability of nonunion. Smoking and postoperative LISA>45° significantly reduced the probability of bone fusion by approximately 4.4 and 9.5 times, respectively. Patients with reduced vascularity in the nonunion site had a 5.2 times lower chance of bone fusion. Our multivariate logistic regression model can explain 32% of failures after scaphoid reconstruction, including postoperative LISA>45°, patients' present record of smoking, and reduced vascularity in the nonunion site. However, bone graft type does not impact the union rate in general; however, in case of AVN, the tendency toward higher union rates was observed for medial femoral condyle free flaps when compared to other types of graft (non-vascularized and pedicled bone grafts considered as one group, p = 0.09).

Development of Cu application using dual-energy computed tomography for detecting medication-related osteonecrosis of the jaw.

INTRODUCTION: The present study developed an application using dual-energy computed tomography (DECT) focused on Cu for detecting medication-related osteonecrosis of the jaw (MRONJ). MATERIALS AND METHODS: First, we performed two types of phantom studies using a Cu wire syringe and pig mandible with Cu wire to detect Cu on DECT. Second, DECT examinations of 44 patients with MRONJ were performed to compare lesion and normal bone sites using single-energy CT, DECT-virtual non-calcium (VNCa), and DECT-Cu applications. Quantitative analyses of VNCa CT and CT values were performed, and a cut-off value was calculated using receiver operating characteristic analysis. Third, we compared the Cu content in the MRONJ and normal bone groups using inductively coupled plasma atomic emission spectroscopy (ICP-AES). RESULTS: The material-specific differences in attenuation between the two different energies enabled the accurate separation of Cu from Ca in phantom studies. The sensitivity and specificity for single-energy CT, DECT-VNCa, and DECT-Cu applications were 97.7% and 2.3%, 86.4% and 81.8%, and 88.6% and 97.7%, respectively. Thus, VNCa CT values obtained on DECT-Cu application images showed the highest area under the curve value and maximal diagnostic efficacy in differentiating lesion sites from normal bone sites. On ICP-AES analyses, the Cu content was significantly higher in the MRONJ group than in the normal bone group. CONCLUSION: DECT-Cu application demonstrated better diagnostic performance in detecting MRONJ compared with single-energy CT or DECT-VNCa.

Management of Talar Avascular Necrosis with Total Talus.

Avascular necrosis (AVN) of the talus is a difficult pathology to treat. Patient-specific factors such as functional status, comorbidities should be considered. Previous standard care for talar AVN was centered around arthrodesis procedures and loss of motion about the joints of the rearfoot and ankle. With the advent of 3D printed talar implants, patients are afforded an option to maintain ankle joint motion. Literature is limited due to the recent development of total talus replacement (TTR) technology. This article aims to review literature, surgical techniques, and pearls to better help foot and ankle surgeons treat cases of talar AVN.

Knee Osteonecrosis After SARS-CoV-2 Virus Infection.

ABSTRACT: Osteonecrosis after COVID-19 infection is a complex pathology with multifactorial origin. Factors such as infection itself with associated coagulopathy, as well as genetic mechanisms, and medications used for its treatment such as corticosteroids, may also be involved. The variability in the presentation makes diagnosis difficult, which, if done soon, can help delay progression and reduce morbidity and the need for surgery.This report presents a case of knee osteonecrosis in a female patient who did not have previous knee pathology on imaging tests. She was diagnosed by magnetic resonance imaging months after hospital admission for SARS-CoV-2 pneumonia, which required high-dose corticosteroid treatment.

Case report: golimumab-related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw is an uncommon but highly morbid adverse event of certain medical therapies. Although classically induced by bisphosphonates, the recent advent of monoclonal antibodies is contributing to a rise in cases. In this case report, we present a rare case of golimumab-associated medication-related osteonecrosis of the jaw and discuss the possible mechanisms of pathogenesis.

Surgical treatment of subchondral osteonecrosis of the humeral head: A case report and literature review.

BACKGROUND: Osteonecrosis of the humeral head is an uncommon subchondral bone disease with many etiologies, and there is currently no definite evidence to support an optimal surgical treatment plan. We report a case of surgical treatment of left humeral head necrosis. To the best of our knowledge, this is the youngest patient with non-drug-induced humeral head necrosis and the largest collapsed area. CASE PRESENTATION: The case involved a 16-year-old male who injured his left shoulder 1 year ago. The patient was admitted to the hospital because of shoulder pain after activity in the year following the injury. During the physical examination, the left glenohumeral joint space was tender, the pain was obvious when the shoulder joint was rotated and squeezed, and the active and passive range of motion was normal. X-ray, magnetic resonance imaging, and computed tomography + 3D computed tomography scans all showed subchondral osteonecrosis of the left humeral head. Left humeral head lesion removal and autologous osteochondral transplantation were performed, and the patient was followed up. CONCLUSION: Non-drug-induced humeral head necrosis is rare. Autologous osteochondral transplantation is currently one of the most mature and effective treatment methods. The short-term curative effect in this patient is satisfactory, but the patient is young and has a large collapsed area, so long-term follow-up is worthwhile.

Core decompression is superior to nonoperative management for humeral head osteonecrosis: a systematic review.

BACKGROUND: Much of the literature on osteonecrosis has traditionally focused on the hip, which remains the most common site for this disease. The shoulder and the knee are the second most frequently affected sites (both approximately 10% of the incidence). There are a variety of techniques for managing this disease, and it is important to optimize this for our patients. This review aimed to compare the results of core decompression (CD) vs. nonoperative modalities for the treatment of osteonecrosis of the humeral head, including (1) success rate defined as lack of progression to further procedures (shoulder arthroplasty) and no need for further intervention; (2) clinical results (patient-reported pain and functional scores); and (3) radiological outcomes. METHODS: We queried PubMed and found 15 reports that fit the inclusion criteria for studies concerning the use of CD as well as studies discussing nonoperative treatment for stage I-III osteonecrotic lesions of the shoulder. A total of 9 studies encompassed 291 shoulders that underwent CD analyzed at a mean follow-up of 8.1 years (range, 67 months-12 years), and 6 studies examined 359 shoulders that underwent nonoperative management at a mean follow-up of 8.1 years (range, 35 months-10 years). Outcomes of CD and nonoperative management included success rate, number of shoulders requiring shoulder arthroplasty, and evaluation of several normalized patient-reported outcomes. We also assessed radiographic progression (pre- to postcollapse or further collapse progression). RESULTS: The mean success rate of CD for avoiding further procedures was 76.6% (226 of 291 shoulders) in stage I through stage III. Stage III shoulders avoided shoulder arthroplasty in 63% (27 of 43 shoulders). Nonoperative management resulted in a success rate of 13%, P < .001. In the CD studies, 7 of 9 showed improvements in clinical outcome measurements compared with 1 of 6 of the nonoperative studies. Radiographically, there was less progression in the CD group (39 of 191 shoulders [24.2%]) vs. the nonoperative group (39 of 74 shoulders [52.3%]) (P < .001). CONCLUSIONS: Given the high success rate and positive clinical outcomes reported, CD is an effective method for management, especially when compared with nonoperative treatment methods for stage I-III osteonecrosis of the humeral head. The authors believe that it should be used as treatment to avoid arthroplasty in patients who have osteonecrosis of the humeral head.

Artificial Lunate Arthroplasty for Kienböck Disease With Multiple Extensor Tendon Ruptures: A Case Report.

CASE: A 73-year-old woman presented with wrist pain and loss of extension in the middle and ring fingers. Radiography revealed a dorsally displaced lunate fragment, resulting in a diagnosis of Kienböck disease with extensor tendon rupture. Artificial lunate replacement and tendon transfer were performed as treatment. Two years postoperatively, the pain was relieved, and the extension lag was 0°. The wrist motion and carpal height had also improved. CONCLUSION: Lunate excision, partial wrist arthrodesis, or proximal row carpectomy are known treatments for Kienböck disease with extensor tendon rupture. Lunate arthroplasty is a novel, useful treatment option for this condition.

Reductions in Bone Mineral Density Are Apparent Early in Children With Prevalent Osteonecrosis Lesions Following Leukemia Therapy.

Osteonecrosis (ON) is a serious complication of childhood acute lymphoblastic leukemia. We determined the prevalence of osteonecrotic lesions in our patient population by a one-time multisite magnetic resonance imaging (MRI) more than 1 year following leukemia therapy. MRI findings were evaluated in relationship to clinical factors (including longitudinal changes in bone mineral density [BMD]). Eighty-six children enrolled in the Steroid Associated Osteoporosis in the Pediatric Population (STOPP) study were evaluated for ON at 3.1 ± 1.3 years following therapy. Thirty children had a total of 150 confirmed ON lesions (35%). Lumbar spine (LS) BMD Z-scores (mean ± SD) were low at diagnosis and similar between patients with and without ON (-1.09 ± 1.53 versus -1.27 ± 1.25, p = 0.549). LS BMD Z-scores declined from baseline to 12 months in children with ON (-0.31 ± 1.02) but not in those without (0.13 ± 0.82, p = 0.035); the hip BMD Z-scores from baseline to 24 months declined in both groups, but to a greater extent in those with ON (-1.77 ± 1.22) compared to those without (-1.03 ± 1.07, p = 0.045). At the time of the MRI, mean total hip and total body (TB) BMD Z-scores were lower in children with ON (hip -0.98 ± 0.95 versus -0.28 ± 1.06, p = 0.010; TB -1.36 ± 1.10 versus -0.48 ± 1.50, p = 0.018). Pain occurred in 11/30 (37%) with ON versus 20/56 (36%) without, p = 0.841. In multivariable models, older age at diagnosis (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.15-2.13; p = 0.004), and hip BMD Z-score at MRI (OR 2.23; 95% CI, 1.02-4.87; p = 0.046) were independently associated with ON. Overall, one-third of children demonstrated ON after leukemia therapy. Those with ON had greater reductions in spine and hip BMD Z-scores in the first 1 and 2 years of therapy, respectively. Older age and lower hip BMD Z-scores at MRI were significantly associated with prevalent, off-therapy ON. These data assist in identifying children at risk of ON. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

A novel classification of Kienbock's disease based on magnetic resonance imaging.

PURPOSE: We devised a classification system for Kienbock's disease using magnetic resonance imaging (MRI). Moreover, we compared it with the modified Lichtman classification and evaluated the inter-observer reliability. METHODS: Eighty-eight patients diagnosed with Kienbock's disease were included. All patients were classified using the modified Lichtman and MRI classifications. MRI staging was based on factors including partial marrow oedema, cortical integrity of the lunate, and dorsal subluxation of the scaphoid. The inter-observer reliability was evaluated. We also evaluated the presence of a displaced coronal fracture of the lunate and investigated its association with the presence of a dorsal subluxation of the scaphoid. RESULTS: Seven patients were categorized into stage I, 13 into II, 33 into IIIA, 33 into IIIB, and two into IV using the modified Lichtman classification. Six patients were categorized into stage I, 12 into II, 56 into IIIA, ten into IIIB, and four into IV using the MRI classification. The greatest shift between the stages was observed in stages IIIA and IIIB when the results of the two classification systems were compared. The inter-observer reliability of the MRI classification was greater than that of the modified Lichtman classification. Fifteen cases with a displaced coronal fracture of the lunate were identified, and a dorsal subluxation of the scaphoid was significantly more present in these patients. CONCLUSION: The MRI classification system is more reliable than is the modified Lichtman classification. MRI classification reflects carpal misalignment with higher fidelity and is more appropriate for classification into stages IIIA and IIIB.

Imaging of Müller-Weiss Disease.

Müller-Weiss disease (MWD) is the result of a dysplasia of the tarsal navicular bone. Over the adult years, the dysplastic bone leads to the development of an asymmetric talonavicular arthritis with the talar head shifting laterally and plantarly, thus driving the subtalar joint into varus. From a diagnostic point of view, the condition may be difficult to differentiate from an avascular necrosis or even a stress fracture of the navicular, but fragmentation is the result of a mechanical impairment rather than a biological dysfunction.Standardized weight-bearing radiographs (anteroposterior and lateral views) of both feet are usually enough to diagnose MWD. Other imaging modalities such as multi-detector computed tomography and magnetic resonance imaging in early cases for the differential diagnosis can add additional details on the amount of cartilage affected, bone stock, fragmentation, and associated soft tissue injuries. Failure to identify patients with paradoxical flatfeet varus may lead to an incorrect diagnosis and management. Conservative treatment with the use of rigid insoles is effective in most patients. A calcaneal osteotomy seems to be a satisfactory treatment for patients who fail to respond to conservative measures and a good alternative to the different types of peri-navicular fusions. Weight-bearing radiographs are also useful to identify postoperative changes.