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Concept: Avascular necrosis


BACKGROUND: The most common mechanical failure in the internal fixation of trochanteric hip fractures is the cut-out of the sliding screw through the femoral head. Several factors that influence this complication have been suggested, but there is no consensus as to the relative importance of each factor.The purpose of this study was to analyse the cut-out complication with respect to the following variables: patients` age, fracture type, fracture reduction, implant positioning and implant design. METHODS: 3066 consecutive patients were treated for trochanteric fractures with Gamma Nails between 1990 and 2002 at the Centre de Traumatologie et de l`Orthopedie (CTO), Strasbourg, France. Cut-out complications were identified by reviewing all available case notes and radiographs. Subsequently, the data were analysed by a single reviewer (AJB) with focus on the studied factors. RESULTS: Seventy-one cut-out complications were found (2.3%) of the 3066 trochanteric fractures. Cut-out failure associated with avascular head necrosis, pathologic fracture, deep infection or secondary to prior failure of other implants were excluded from the study (14 cases). The remaining 57 cases (1.85 %, median age 82.6, 79% females) were believed to have a biomechanical explanation for the cut-out failure. 41 patients had a basicervical or complex fracture type. A majority of cut-outs (43 hips, 75%) had a combination of the critical factors studied; non-anatomical reduction, non-optimal lag screw position and the characteristic fracture pattern found. CONCLUSIONS: The primary cut-out rate of 1.85% was low compared with the literature. A typical cut-out complication in our study is represented by an unstable fracture involving the trochanteric and cervical regions or the combination of both, non-anatomical reduction and non-optimal screw position. Surgeons confronted with proximal femoral fractures should carefully scrutinize preoperative radiographs to assess the primary fracture geometry and fracture classification. To reduce the risk of a cut-out it is important to achieve both anatomical reduction and optimal lag screw position as these are the only two factors that can be controlled by the surgeon.

Concepts: Osteoporosis, Bone fracture, Hip fracture, Hip replacement, Orthopedic surgery, Avascular necrosis, Cultural studies, Bone fractures


Idiopathic avascular necrosis (AVN) of bone causes significant morbidity in adults although the pathophysiology is unknown. The present treatment options include systemic biphosphonate therapy and local bone drilling decompression, ameliorating the healing process and their by render the weight bearing femur head less vulnerable to collapse. In the present study we demonstrate the involvement of heparanase in AVN and in the acceptable treatments.

Concepts: Inflammation, Present, Healing, Heart, Femur, Avascular necrosis, 2006 albums, Femur head


An increase in interstitial fluid is an expression of bone marrow edema (BME) and osteonecrosis (ON). The exact pathogenetic processes still remain unknown. Treatment options are mainly symptomatic with core decompression as surgical golden standard with immediate pain relief. Recently, it has been shown that intravenous iloprost can be used to achieve a reduction in BME and ON with a considerable improvement in the accompanying symptoms. The effect of intraveneously applied iloprost alone (12 patients) was studied against core decompression alone (12 patients) as well as iloprost following core decompression (12 patients). We could find a significant improvement in HHS, WOMAC score, SF-36 score and VAS 3 months and 1 year after therapeutical intervention in all treatment groups; however, statistically best results were obtained by combination. Concerning the MRI scans, we found a distinct reduction in BME in all groups again favoring the combination. Concerning ON, the results were not as promising as for BME. Intravenous prostacyclin and core decompression as monotherapy are of efficient therapeutical benefit in the treatment of BME, and the combination of both methods, however, seems to be most promising, also in the treatment of ON. Long-term results and higher number of patients are needed for final statements.

Concepts: Bone marrow, Lymphatic system, Avascular necrosis, Diving medicine, Osteochondritis dissecans, Femur head, Epiphysis, Dysbaric osteonecrosis


49, XXXXY is a rare aneuploidy and variant of Klinefelter syndrome, occurring in 1 per 80,000-100,000 live births. We present a cohort of 40 affected males, focusing on musculoskeletal problems. Subjects were participants in an annual 49er family support group meeting. Children were examined in a multidisciplinary clinic by a pediatric neurologist and geneticist, a pediatric orthopedist, a neurodevelopmentalist, and two physical therapists. The patient data were collected from this clinic from 2004 to 2012. All patients were required to have karyotypes that confirmed the presence of XXXXY. There was a high prevalence of musculoskeletal disorders, particularly hypotonia (34 patients [85%]), radioulnar synostosis (30 [75%]), pes planus (26 [65%]), asymmetric hip rotation (27 [67.5%]), and clinodactyly (24 [60%]). Other, less common lower-extremity disorders, included, 5 patients (12.5%) with unilateral club foot, 5 boys (12.5%) with pes cavus, 10 patients (25%) genu valgum and 2 children with genu varus (5%). To our knowledge, this is the first large cohort of boys with 49, XXXXY that focuses on musculoskeletal disorders. There was an increased incidence of hypotonia, clubfoot, avascular necrosis of the femoral head, radioulnar synostosis, and pes planus compared to the normative population. Boys with 49, XXXXY would benefit from multidisciplinary evaluations, particularly from pediatric orthopedists, physical therapists, neurologists, and geneticists for appropriate medical care. © 2013 Wiley Periodicals, Inc.

Concepts: Varus deformity, Neurology, Avascular necrosis, Klinefelter's syndrome, Aneuploidy, Genu valgum, Genu varum, Congenital disorders of musculoskeletal system


Preoperative Bryant’s overhead traction before closed reduction (CR) in developmental dysplasia of the hip (DDH) remains controversial and its success in increasing CR rates and reducing avascular necrosis (AVN) rates has not been specifically reported in a large cohort.

Concepts: Redox, Avascular necrosis


Osteonecrosis of the femoral head is a debilitating disease that involves impaired blood supply to the femoral head and leads to femoral head collapse.

Concepts: Immune system, Cancer, Genetic disorder, Mutation, Blood, Avascular necrosis, Femur head


The Disease Severity Scoring System (DS3) is a validated measure for evaluating Gaucher disease type 1 (GD1) severity. We developed a new framework, consisting of health states, transition probabilities between those states, and preferences for those states (utilities) based on the DS3 to predict long-term outcomes of patients starting treatment. We defined nine mutually exclusive (alive) health states based on three DS3 categories: mild (0 ≤ DS3 ≤ 3.5) without symptoms of bone disease; mild with bone pain, mild with severe skeletal complications (SSC) defined as lytic lesions, avascular necrosis, or fracture; moderate (3.5 < DS3 ≤ 6.5) without SSC; moderate with SSC; marked (6.5 < DS3 ≤ 9.5) without SSC; marked with SSC; severe (9.5 < DS3 ≤ 19) without SSC; and severe with SSC. Health-state transition probabilities and utilities were estimated from a longitudinal sample of patients with GD1 who started enzyme replacement therapy (the DS3 Score Study). Age dependent GD1-specific mortality was derived from published data. We used a Markov state-transition model to illustrate how to estimate time spent in each health state.

Concepts: Osteoporosis, Medicine, Epidemiology, Statistics, Skeletal system, Therapy, Avascular necrosis, Gaucher's disease


Idiopathic osteonecrosis of the femoral head (IONFH) is an ischemic disorder that causes bone necrosis of the femoral head, resulting in hip joint dysfunction. IONFH is a polygenic disease and steroid and alcohol have already known to increase its risk; however, the mechanism of IONFH remains to be elucidated. We performed a genome-wide association study using ~60,000 subjects and found two novel loci on chromosome 20q12 and 12q24. Big data analyses identified LINC01370 as a candidate susceptibility gene in the 20q12 locus. Stratified analysis by IONFH risk factors suggested that the 12q24 locus was associated with IONFH through drinking capacity. Our findings would shed new light on pathophysiology of IONFH.

Concepts: Gene, Genetics, Chromosome, Femur, Genome-wide association study, Hip, Avascular necrosis, Necrosis


Legg-Calvé-Perthes' disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition.

Concepts: Blood vessel, Avascular necrosis, Osteochondritis dissecans, Epiphysis


Background and purpose - Increasing numbers of shoulder arthroplasty are performed internationally. The predictors of intraoperative complications when implanting primary shoulder replacements are unknown. We determined the incidence of intraoperative complications during primary shoulder arthroplasty using the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man (NJR), and analyzed the associated risk factors for complications. Patients and methods - NJR data on primary shoulder arthroplasty were scrutinized for intraoperative complications. 2 analyses were performed: the first examined the incidence and predictors of any recorded complication; the second examined the incidence and predictors for intraoperative fractures specifically. Analysis of risk factors was performed using multivariable binary logistic regression modeling. Results - 12,559 primary shoulder arthroplasties were recorded, with an intraoperative complication rate of 2.5%, the majority being fractures (1.6% overall). The incidence of all complications was lower in men (RR vs. women =0.63 (95% CI 0.47-0.84)). Patients undergoing surgery for avascular necrosis (RR =2.3 (1.3-4.2)) or trauma sequelae (RR =1.6 (1.2-2.7)) had a higher risk of complications compared with OA. Patients undergoing a stemmed hemiarthroplasty (RR =1.8 (1.2-2.5)) and reverse shoulder arthroplasty (RR 1.6 (1.1-2.5)) had a higher risk of complications compared with total shoulder arthroplasty. The incidence of all complications was less in patients undergoing resurfacing arthroplasty (vs. total shoulder arthroplasty (RR 0.42 (0.24-0.73)) and when performing the superior approach (vs. deltopectoral (RR 0.56 (0.39-0.80)). Interpretation - This is the first study to use a national data set to examine risk factors for intraoperative complications during all types of primary shoulder arthroplasty, and identifies several previously unrecognized risk factors, such as surgical approach.

Concepts: Regression analysis, Logistic regression, Avascular necrosis, Sequela, Late effect, Order theory, Complication, Isle of Man