BMP6 and VDR gene polymorphisms are associated with osteonecrosis in a sickle cell anaemia cohort.

The occurrence and severity of osteonecrosis in sickle cell anaemia (SCA) vary due to risk factors, including genetic modifiers. Bone morphogenetic proteins (BMPs), particularly BMP6, and the vitamin D receptor (VDR) play key roles in cartilage and bone metabolism, making them potential contributors to orthopaedic outcomes in SCA. Here, we evaluated the association of polymorphisms in BMP6 (rs3812163, rs270393 and rs449853) and VDR (FokI rs2228570 and Cdx2 rs11568820) genes with osteonecrosis risk in a Brazilian SCA cohort. A total of 177 unrelated SCA patients were selected. The AA genotype of BMP6 rs3812163 was independently associated with a lower osteonecrosis risk (p = 0.015; odds ratio (OR): 0.38; 95% confidence interval (CI): 0.18-0.83) and with the long-term cumulative incidence of osteonecrosis (p = 0.029; hazard ratio: 0.56, 95% CI: 0.34-0.94). The VDR rs2228570 TT genotype was independently associated with a lower osteonecrosis risk (p = 0.039; OR: 0.14; 95% CI: 0.02-0.90). In summary, our results provide evidence that BMP6 rs3812163 and the VDR rs2228570 might be implicated in osteonecrosis pathophysiology in SCA and might help identify individuals at high risk.

Proteomic profiling of extracellular vesicles derived from human serum for the discovery of biomarkers in Avascular necrosis.

BACKGROUND: Avascular necrosis (AVN) is a medical condition characterized by the destruction of bone tissue due to a diminished blood supply. When the rate of tissue destruction surpasses the rate of regeneration, effective treatment becomes challenging, leading to escalating pain, arthritis, and bone fragility as the disease advances. A timely diagnosis is imperative to prevent and initiate proactive treatment for osteonecrosis. We explored the potential of differentially expressed proteins in serum-derived extracellular vesicles (EVs) as biomarkers for AVN of the femoral head in humans. We analyzed the genetic material contained in serum-derived exosomes from patients for early diagnosis, treatment, and prognosis of avascular necrosis. METHODS: EVs were isolated from the serum of both patients with AVN and a control group of healthy individuals. Proteomic analyses were conducted to compare the expression patterns of these proteins by proteomic analysis using LC-MS/MS. RESULTS: Our results show that the levels of IGHV3-23, FN1, VWF, FGB, PRG4, FCGBP, and ZSWIM9 were upregulated in the EVs of patients with AVN compared with those of healthy controls. ELISA results showed that VWF and PRG4 were significantly upregulated in the patients with AVN. CONCLUSIONS: These findings suggest that these EV proteins could serve as promising biomarkers for the early detection and diagnosis of AVN. Early diagnosis is paramount for effective treatment, and the identification of new osteonecrosis biomarkers is essential to facilitate swift diagnosis and proactive intervention. Our study provides novel insights into the identification of AVN-related biomarkers that can enhance clinical management and treatment outcomes.

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.

Natural course of talar avascular necrosis during short-term follow-up and factors associated with Disease progression.

BACKGROUND: This retrospective cohort study aimed to investigate the natural history of talar avascular necrosis (AVN) during short-term outpatient follow-up and to identify the risk factors for progression to collapse and arthritic changes. METHODS: Thirty-four cases of talar AVN from 34 patients (15 males, 19 females) were included. The mean age of the patients was 48.9 years (SD 16.0 years) and the mean follow-up period was 39.5 months (SD 42.0 months). The patients were divided into two groups i.e., progression and non-progression groups. The progression group consisted of those who showed aggravation of the Ficat stage during the follow-up period or advanced arthritis of the ankle joint (Ficat stage 4) at presentation. Demographic data and information regarding BMI, medical comorbidities, trauma history, bilaterality, and location of the lesion (shoulder vs. non-shoulder lesions) were collected. Following the univariate analysis, a binary logistic regression analysis was performed. RESULTS: The location of the talar AVN was the only significant factor (p = 0.047) associated with disease progression. A total of 14.3% (2 of 14) of the central (non-shoulder) talar AVN lesions showed progression, while 50% (10 of 20) of shoulder lesions aggravated during follow-up. Age, sex, bilaterality, medical comorbidities, and trauma history were not associated with progressive talar collapse or subsequent arthritic changes in talar AVN. CONCLUSIONS: Conservative treatment should be considered for a central lesion of the talar AVN because it tends to remain stable without progression. A more comprehensive study with a larger study population is required to establish the surgical indications for talar AVN. LEVEL OF EVIDENCE: Prognostic level III.

Risk factors for avascular necrosis of the femoral head after developmental hip dislocation reduction surgery and construction of Nomogram prediction model.

BACKGROUND: To analyze the risk factors for the development of avascular necrosis (AVN) of the femoral head after reduction surgery in children with developmental hip dysplasia (DDH), and to establish a prediction nomogram. METHODS: The clinical data of 134 children with DDH (169 hips) treated with closure reduction or open reduction from December 2016 to December 2019 were retrospectively analyzed. Independent risk factors for AVN after DDH reduction being combined with cast external immobilization were determined by univariate analysis and multivariate logistic regression and used to generate nomograms predicting the occurrence of AVN. RESULTS: A total of 169 hip joints in 134 children met the inclusion criteria, with a mean age at surgery of 10.7 ± 4.56 months (range: 4-22 months) and a mean follow-up duration of 38.32 ± 27.00 months (range: 12-94 months). AVN developed in 42 hip joints (24.9%); univariate analysis showed that the International Hip Dysplasia Institute (IHDI) grade, preoperative development of the femoral head ossification nucleus, cartilage acetabular index, femoral head to acetabular Y-shaped cartilage distance, residual acetabular dysplasia, acetabular abduction angle exceeding 60°, and the final follow-up acetabular index (AI) were associated with the development of AVN (P < 0.05). Multivariate logistic regression analysis showed that the preoperative IHDI grade, development of the femoral head ossification nucleus, acetabular abduction angle exceeding 60°, and the final follow-up AI were independent risk factors for AVN development (P < 0.05). Internal validation of the Nomogram prediction model showed a consistency index of 0.833. CONCLUSION: Preoperative IHDI grade, preoperative development of the femoral head ossification nucleus, final AI, and acetabular abduction angle exceeding 60° are risk factors for AVN development. This study successfully constructed a Nomogram prediction model for AVN after casting surgery for DDH that can predict the occurrence of AVN after casting surgery for DDH.

The many faces of sickle cell disease in children: complications in the appendicular skeleton.

Sickle cell disease (SCD) is a hereditary red cell disorder with clinical manifestations secondary to sickling or crescent-shaped distortion of the red blood cells. Musculoskeletal complications of SCD are often the main causes for acute and chronic morbidities in children with manifestations including osteomyelitis, osteoporosis and osteonecrosis. This article aims to familiarise the paediatric radiologist with appendicular skeletal complications of SCD in the paediatric population and their imaging appearance.

Pectoralis major pedicle bone grafting vs. tricortical iliac grafting for Neer 4-part proximal humerus fractures: a randomized controlled trial.

BACKGROUND: The risk of avascular necrosis, nonunion, or malunion is high in osteoporosis-related 4-part fractures. We evaluated the results of patients who underwent plate osteosynthesis with a vascularized pectoralis major graft compared with tricortical iliac grafting to treat 4-part proximal humerus fractures. MATERIAL AND METHODS: Thirty-four patients aged 50-75 years with Neer 4-part proximal humerus fractures were studied. Group A (n = 17) underwent osteotomy of a 2.5 ± 1 cm pectoralis major pedicle bone graft and plate application, whereas group B (n = 17) underwent plate osteosynthesis using iliac autogenous grafts. Final follow-up assessments included evaluation using Constant and American Shoulder and Elbow Surgeons scoring systems, humeral neck-shaft angle (HNSA), humeral head height, and humeral head avascular necrosis. RESULTS: Reduction loss was observed in 3 patients (17.6%) in group A, whereas it was observed in 10 patients (58.8%) in group B (P = .013). Humeral head avascular necrosis was found in 1 patient (5.8%) in group A, whereas it was found in 5 patients (29.4%) in the other group (P = .071). The HNSA was normal in 12 (70.5%) of group A patients, whereas it was normal in 6 (35.2%) of group B patients. The HNSA was weak or bad (<1200) in 29.4% of group A patients, whereas this rate was 64.7% in group B patients. Humeral head height was 2.64 ± 1.45 mm in group A and 3.66 ± 1.65 mm in group B. There were no statistically significant differences between the 2 groups in terms of Constant and American Shoulder and Elbow Surgeons scoring systems. CONCLUSION: Pectoralis major bone pedicle graft in Neer 4-part proximal humerus fractures reduces the risk of avascular necrosis and nonunion rates. Our technique yielded excellent clinical and radiological results. We achieved recovery without creating additional donor site morbidity.

No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head.

INTRODUCTION: Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. METHODS: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. RESULTS: In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all). CONCLUSION: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Is COVID-19 an independent risk factor for the development of avascular necrosis of the hip? A retrospective study to evaluate the factors associated with avascular necrosis of the hip in patients who had COVID-19 infection.

PURPOSE: The cumulative effect of hyper-coagulative COVID-19 disease and using steroids leads to increased avascular necrosis (AVN) hip incidence. This study aims to correlate the various factors of COVID-19 infection with the occurrence of AVN hip. METHODS: It is a retrospective cross-sectional study of non-traumatic AVN hip patients with a history of COVID-19 infection. A total number of 50 patients satisfied the inclusion criteria. The following details were obtained: (a) patient's demographics, (b) COVID-19: interval of infection and groin pain, duration of symptoms, severity, steroid intake, (c) AVN hip: involved side, Ficat-Arlet staging. RESULTS: The mean age was 36.3 years (range: 20-60), and body mass index (BMI) was 25.13 kg/m2 (range: 18.50-31.50). There were 45 males and five females. Sixty percent (30) of patients managed at home, 24% (12) required admission into the ward, 2% (1) were in ICU only, and 14% (7) admitted to both ICU and ward. The mean interval of COVID-19 infection and onset of hip pain was 359.02 days (range: 10-822 days). Thirty-eight percent (19) patients required steroids (injection and oral), 46% (23) took steroids (oral only), whereas 16% (8) recovered without steroids. The stage of AVN correlated with the severity of COVID-19 infection (p-value -0.038) and significant improvement in VAS and HHS after treatment in each stage. The mean follow-up was 9.79 months (6-19 months). CONCLUSION: A low-dose steroid intake with moderate to severe COVID-19 infection produces an additive effect on the development of AVN hip. Most affected individuals were adult males, and stage II AVN was the most common, managed with bisphosphonates and core decompression for short intervals.

Risk factor analysis of femoral avascular necrosis after operation for Tönnis grade IV developmental dysplasia of the hip.

PURPOSE: We explored the risk factors for avascular necrosis (AVN) after surgery using open reduction, pelvic osteotomy, and femoral osteotomy for Tönnis grade IV developmental dysplasia of the hip (DDH). METHODS: In this retrospective study, we collected data of patients with Tönnis grade IV DDH treated with open reduction and pelvic osteotomy combined with femoral osteotomy from January 2012 to May 2020. The patients were divided into the AVN group and non-AVN group using the Kalamchi-MacEwen classification system. The clinical and imaging data of the two groups were collected, and the possible risk factors were included in the analysis. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors and odds ratios of AVN. RESULTS: In all, 254 patients (mean age; 2.6±0.9 years, 278 hips) were included. The mean follow-up time was 3.8±1.5 years. A total of 89 hips (32%) were finally classified as AVN (Kalamchi-MacEwen II-IV). Univariate analysis showed significant associations with AVN for age (p=0.006), preoperative femoral neck anteversion (FAV) (p<0.001), femoral osteotomy length to dislocation height ratio (FDR) <1 (p<0.001), and the epiphyseal ossific nucleus diameter to the neck diameter ratio (ENR) <50% (p=0.009). Multivariate logistic regression analysis showed that only excessive preoperative FAV (OR: 1.04; 95% CI: 1.02-1.05; p<0.001) and FDR<1 (OR: 3.58; 95% CI: 2.03-6.31; p<0.001) were independent risk factors for femoral head necrosis. CONCLUSION: Excessive preoperative FAV and FDR<1 are important risk factors for femoral AVN after open reduction, pelvic osteotomy, and femoral osteotomy for Tönnis grade IV DDH. For children with DDH with high dislocation and excessive FAV, clinicians should fully evaluate their condition and design more personalized treatment programs to prevent AVN.

Open reduction after failed closed reduction following failed Pavlik harness treatment in developmental dysplasia of the hip: One- or two-stage?

INTRODUCTION: The current published evidence for the treatment of developmental dysplasia of the hip (DDH) with failed closed reduction (CR) following failed Pavlik harness (PH) treatment is still limited. This study aimed to determine whether an one-stage open reduction (OR) would lead to a similar outcome to a two-stage OR in these patients. Meanwhile, the occurrence of femoral head avascular necrosis (AVN) and further surgery (pelvic osteotomy, PO) within the follow-up period was investigated. MATERIALS AND METHODS: A consecutive series of DDH patients who failed CR following failed PH treatment and received OR finally between January 2008 and December 2020 were studied. The patients were divided into two groups. One group of which received OR immediately after failed CR (one-stage OR group, Group A), and the other received a delayed OR (two-stage OR group, Group B). The McKay's criteria, acetabular index (AI) and the degree of dislocation of the hips were evaluated for the final outcomes. RESULTS: At the last follow-up, 54 (84.4%) of the 64 hips in Group A and 26 (83.9%) of 31 hips in Group B were in excellent or good condition. Comparison between the two groups revealed that there were no differences in terms of McKay grading (P = 0.950), AI (P = 0.783), incidence of AVN (P = 0.745), and also incidence of PO (P = 1.000). However, a significant lower mean AI was found in Group A, when the OR was performed in Group B (31.06 ± 4.45° vs. 33.87 ± 4.12°, P = 0.004). CONCLUSION: Both of the one- and two-stage OR may acheive favorable outcomes. Moreover, one-stage OR is of without the general anesthesia risk associated with two-stage OR. We therefore advocate that an OR should be performed in appropriate DDH patients during the same session once a failed CR is detected.

Do neutrophil/lymphocyte, monocyte/lymphocyte, platelet/lymphocyte ratios affect prognosis and stage in avascular necrosis of the femoral head?

INTRODUCTION: Avascular necrosis of the femoral head (AVNFH) is an osteonecrosis type caused by ischaemic osteocyte loss of femoral head, and its exact pathomechanism is still unknown. Neutrophil, lymphocyte, monocyte, platelet levels in complete blood count and ratios between these levels have been used by almost all medical disciplines as accesible and reliable biomarkers of immune response. Aim of this study is to identify the effects of neutrophil/lymphocyte (NL), monocyte/lymphocyte (ML), platelet/lymphocyte (PLT/L) ratios on prognosis and stage in patients with avascular necrosis of the femoral head (AVNFH). MATERIALS AND METHODS: A total of 106 (30 female; 76 male) patients aged 18 and over diagnosed with avascular necrosis of femoral head between 2012-2022 years were retrospectively evaluated. Study was planned after a total of 106 (30 female, 76 male) healthy patients with consent to participate who were demographically equal to the study group were included in the control group. Patients in the study group were divided into 3 groups as Stage I, II and III according to the Ficat-Arlet classification. RESULTS: In terms of neutrophil counts; neutrophil values of study and control groups were 4.94±1.89 and 4,21±1,17; respectively. There was statistically significant difference between counts (p<0.05). In terms of neutrophil/lymphocyte ratio, NL ratio was statistically significantly higher in study group (2.11±0.85) than control group (1.75±0.44). Cut-off value of NL ratio was 2.13 according to the ROC analysis (sensitivity 47.17% (95% CI (37.4-57.1)); specificity=84.91% 95% GA (76.6-91.1)). Sensitivity and specificity of cut-off value was statistically significant. There was no difference between groups created according to Ficat-Arlet in terms of hemogram parameters. DISCUSSION: NL may indicate AVNFH; however, other parameters are considered as inadequate for identifying an independent marker in AVNFH due to ineffective immune response. Future studies with larger samples which allow standard and multi-dimensional analysis are needed (Tab. 4, Fig. 5, Ref. 20).

[Research progress on mechanism of traditional Chinese medicine intervention in angiogenesis in prevention and treatment of nontraumatic avascular necrosis of femoral head].

Nontraumatic avascular necrosis of the femoral head(NANFH) is a common and refractory femoral head disease that causes bone death due to interruption of blood supply. Early clinical symptoms are atypical, such as hip pain and limited joint function. In the late stage, severe pain, shortening of the affected limb, claudication, and other serious symptoms are common, which se-riously affects the quality of life of patients. Therefore, it is of great significance to actively improve the clinical symptoms of NANFH to enhance the quality of life of patients. The pathogenesis of NANFH is complex, such as traumatic vascular circulatory disorders, the use of hormones or other drugs, alcoholism, and diabetes mellitus. These factors directly or indirectly lead to femoral head vascular damage, thrombosis, and coagulation system disorders, which reduce the blood supply to the acetabulum and femoral head, thus causing ischaemic death of the femoral head or even femoral head collapse. NANFH is mainly categorized as "bone impotence" and "bone paralysis" in traditional Chinese medicine(TCM). The treatment of NANFH with TCM has the characteristics and advantages of a long history, stable and reliable therapeutic effect, fewer adverse reactions, good patient tolerance, and high acceptance. Previous studies have shown that the promotion of angiogenesis is a key initiative in the prevention and treatment of NANFH, and TCM can promote fe-moral head angiogenesis by interfering with the expression of angiogenesis-related factors, which in turn can help to restore the blood supply of the femoral head and thus improve clinical symptoms of NANFH and prevent and treat NANFH. This article described the roles of blood supply interruption and angiogenesis in NANFH and the accumulated knowledge and experience of TCM in NANFH and summarized the role of angiogenesis-related factors in NANFH and the research progress on TCM intervention, so as to provide an idea for the subsequent research and a new basis for the clinical application of TCM in the treatment of NANFH.

Outcomes following total ankle total talus replacement: A systematic review.

BACKGROUND: Prosthetic substitution of the talus presents a significant challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis and eventual talar collapse. The purpose of this systematic review is to evaluate whether total ankle total talus replacement (TATTR) leads to improved clinical and radiographic outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. METHODS: We searched the concepts of talus, prosthesis, and arthroplasty in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through March 9, 2023. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 6) inflammatory arthropathy to tibiotalar joint. Patients less than 18 years of age and manuscripts in non-English languages were excluded. RESULTS: Of the 7625 references, 16 studies met the inclusion criteria, yielding data from 136 patients (139 ankles). The studies varied in design, with case reports and retrospective case series being predominant. The overall weighted average modified Coleman Methodology Score (mCMS) was 70.4 out of 100, indicating moderate flaws in study design that may be subject to various forms of bias and possible confounders. Demographics showed a diverse range of etiologies, with alumina ceramic being the primary prosthesis material. Functional scores demonstrated improvements in dorsiflexion and plantarflexion, although patient-reported outcome measures (PROs) were inconsistently reported. Complications included fractures, heterotopic ossification, prolonged wound healing, and infections. Revision details were sparsely reported. CONCLUSION: TATTR is a promising treatment modality for improving short-term functional outcomes for patients with avascular necrosis or trauma-related issues. However, this systematic review underscores the need for standardized reporting, longer-term follow-ups, and further research to establish the procedure's efficacy and safety, particularly in comparison to other treatment modalities. LEVEL OF EVIDENCE: III, Systematic Review of Level IV Studies.

Long-term clinical and radiological results after scaphoid non-union treatment: a retrospective study about 60 cases.

PURPOSE: Scaphoid non-union treatment remains nonconsensual and is based on vascularized or non-vascularized bone grafting. This study aimed to evaluate with a long follow-up the functional, clinical, and radiological outcomes, reported complications and reoperations and studied non-union treatment prognostic factors. METHODS: Patients who had undergone bone graft surgery for scaphoid non-union were retrospectively reviewed. The evaluated outcomes were pain, qDASH, PRWE and MWS scores, active range of motion, grip strength, union rate, scapholunate angle, carpal height, and presence of arthrosis. Complications and reinterventions were also reported. RESULTS: This study included 60 scaphoid non-union treatments with a mean follow-up of 7.7 (1.5-20.3) years. Twenty (33.3%) non-unions were located at the proximal pole, including 6 (10%) with preoperative avascular necrosis (AVN). Union occurred in 51 patients (85%). The functional, clinical, and radiological results were good. The complication rate was 21.3% and the reintervention rate was 16.7%. Subgroup union rate analysis found no difference if the non-union is localized in the proximal pole or if there is AVN. CONCLUSION: With a representative sample of the population and a long follow-up, we have found a good union rate, clinical and functional results regardless of the treatment method chosen. Scaphoid non-union treatment is still controversial and more studies are needed to accurate indications of each graft according to the patient and non-union characteristics. LEVEL OF EVIDENCE IV: Retrospective cohort study.

A prognostic classification of proximal humerus fractures: the cephalic extension staging.

PURPOSE: Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN). METHODS: We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN. RESULTS: The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head. CONCLUSION: Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis.

Low avascular necrosis rates in femoral neck fractures: efficacy of cannulated screw fixation.

PURPOSE: Cannulated screw fixation for femoral neck fractures is often limited by concerns of avascular necrosis (AVN) occurring, historically seen in 5-40% of fixed intracapsular fractures. This study aims to assess the outcomes, particularly the AVN rate, associated with current surgical techniques within our unit. METHODS: We conducted a single-center cross-sectional study, manually searching operative records between July 14, 2014, and December 1, 2018, identifying patients with intracapsular fractured neck of femur fixed with cannulated screws, with a minimum of two years follow-up. Patient records and radiographs were reviewed for clinical and radiographic diagnoses of AVN, non-union, post-operative metalwork infection, and screw penetration of the head. Additionally, fracture pattern and displacement, screw configuration, reduction techniques, and adequacy of reduction were recorded, with radiographs independently analyzed by four orthopedic surgeons. RESULTS: Fifty-six patients were included; average age of 67 years (range 30-100). Forty-two patients (75%) sustained displaced fractures and 14 patients (25%) had undisplaced fractures. Two (4%) patients developed AVN, with no cases of non-union, post-operative metalwork infection or screw penetration of the head. Eight patients (14%) sustained a high-energy injury, though none of these patients developed AVN. All fractures required closed reduction; no open reductions performed. Twenty-seven (64%) of reductions were adequate. CONCLUSION: Our observed AVN rate is notably lower than the widely reported figures, even among a significant proportion of displaced fractures that were fixed. This study underscores that with adequate fixation, cannulated screws represent an excellent option for treating intracapsular neck of femur fractures, even in cases of displaced fracture patterns with imperfect reduction.

Occult ischemic bone lesions in children with sickle cell disease: A study of prevalence.

INTRODUCTION: Avascular necrosis (AVN) is a severe complication of sickle cell disease (SCD) and involves principally the femoral head. Few data exist about the prevalence of lesions in other segments. METHODS: In this cross-sectional study, 42 children (20 males and 22 females) underwent a magnetic resonance imaging (MRI) of the spine, upper arms, and femurs. The primary outcome was to define the prevalence and locations of bone infarcts. RESULTS: Forty-two patients completed the study; the total median age was 11.9 years (interquartile range = 9.5-13.9). Eleven patients (26.2%) were positive for altered bone findings for a total of 32 lesions. Most of the lesions were in the humerus 17 (53.1%), 11 (34.4%) in the femurs, and 4 (12.5%) in the vertebrae. The median number of vaso-occlusive crises (VOCs) was two and four for patients without and with bone lesions, respectively (p = .01). The annual rate of VOC is the best marker for the positive MRI (odds ratio = 82.6; p = .03), and it is correlated with the number of sites involved (p = .02). CONCLUSIONS: Our study highlights that the prevalence of skeletal lesions could be underestimated, and it provides the basis for clinical reasoning and tailored therapy in SCD children.

Femoral head avascular necrosis in COVID-19 survivors: a systematic review.

The current systematic review aimed to document published cases of femoral head avascular necrosis (FHAVN) post-COVID-19, to report the COVID-19 disease characteristics and management patients received, and to evaluate how the FHAVN were diagnosed and treated among various reports. A systematic literature review was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines through a comprehensive English literature search on January 2023 through four databases (Embase, PubMed, Cochrane Library, and Scopus), including studies reporting on FHAVN post-COVID-19. Fourteen articles were included, ten (71.4%) were case reports, and four (28.6%) case series reported on 104 patients having a mean age of 42.2 ± 11.7 (14:74) years, in which 182 hip joints were affected. In 13 reports, corticosteroids were used during the COVID-19 management plan for a mean of 24.8 ± 11 (7:42) days, with a mean prednisolone equivalent dose of 1238.5 ± 492.8 (100:3520) mg. A mean of 142.1 ± 107.6 (7:459) days passed between COVID-19 diagnosis and FHAVN detection, and most of the hips were stage II (70.1%), and concomitant septic arthritis was present in eight (4.4%) hips. Most hips (147, 80.8%) were treated non-surgically, of which 143 (78.6%) hips received medical treatment, while 35 (19.2%) hips were surgically managed, 16 (8.8%) core decompression, 13 (7.1%) primary THA, five (2.7%) staged THA and three (1.6%) had first stage THA (debridement and application of antibiotic-loaded cement spacer). The outcomes were acceptable as regards hip function and pain relief. Femoral head avascular necrosis post-COVID-19 infection is a real concern, primarily attributed to corticosteroid usage, besides other factors. Early suspicion and detection are mandatory, as conservative management lines are effective during early stages with acceptable outcomes. However, surgical intervention was required for progressive collapse or patients presented in the late stage.

Avascular necrosis during alectinib treatment: Case report.

CASE REPORT: We present our patient who used alectinib due to anaplastic lymphoma kinase positivity and developed avascular necrosis in the femoral head. MANAGEMENT AND OUTCOME: In our patient who had been taking alectinib for a long time due to anaplastic lymphoma kinase positivity, avascular necrosis of the femoral head was detected as a result of the examination performed due to hip pain. Due to the responsibility of the disease, her treatment continued by making profit and loss account. DISCUSSION: Femoral head avascular necrosis can be seen with tyrosine kinase inhibitors, although it is very rare. This is the case in the literature to develop avascular necrosis due to alectinib. We think that femoral head necrosis may develop in the patient group using alectinib and care should be taken in this regard.