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Purpose: Identify the presence of a dysfunctional electroencephalographic (EEG) pattern in individuals with sickle cell disease (SCD) and hip osteonecrosis, and assess its potential associations with depression, anxiety, pain severity, and serum levels of brain-derived neurotrophic factor (BDNF)., Methods: In this cross-sectional investigation, 24 SCD patients with hip osteonecrosis and chronic pain were matched by age and sex with 19 healthy controls. Resting-state EEG data were recorded using 32 electrodes for both groups. Power spectral density (PSD) and peak alpha frequency (PAF) were computed for each electrode across Delta, Theta, Alpha, and Beta frequency bands. Current Source Density (CSD) measures were performed utilizing the built-in Statistical nonparametric Mapping Method of the LORETA-KEY software., Results: Our findings demonstrated that SCD individuals exhibited higher PSD in delta and theta frequency bands when compared to healthy controls. Moreover, SCD individuals displayed increased CSD in delta and theta frequencies, coupled with decreased CSD in the alpha frequency within brain regions linked to pain processing, motor function, emotion, and attention. In comparison to the control group, depression symptoms, and pain intensity during hip abduction were positively correlated with PSD and CSD in the delta frequency within the parietal region. Depression symptoms also exhibited a positive association with PSD and CSD in the theta frequency within the same region, while serum BDNF levels showed a negative correlation with CSD in the alpha frequency within the left insula., Conclusion: This study indicates that individuals with SCD experiencing hip osteonecrosis and chronic pain manifest a dysfunctional EEG pattern characterized by the persistence of low-frequency PSD during a resting state. This dysfunctional EEG pattern may be linked to clinical and biochemical outcomes, including depression symptoms, pain severity during movement, and serum BDNF levels., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In late Kienbӧck's, the lunate is fully fragmented and nonreconstructible. Replacing the lunate with a pyrocarbon prosthesis preserves load distribution and avoids carpectomy or fusion, but leaves the wrist intrinsically unstable, requiring additional soft-tissue stabilization techniques., Methods: Five men and 7 women with a mean age of 43 (±15) years underwent prosthetic replacement of the lunate with dual bundle scaphoid-triquetrum tenodesis for carpal stabilization. The mean follow-up interval from initial surgery was 9.1 (±1.7) years. Outcomes were Disabilities of Arm, Shoulder, and Hand (DASH) score, revision or conversion surgery, and wrist range of motion., Results: The mean DASH score was 8.9 (±7.1). No patients reported any additional revision or conversion surgery. The mean wrist flexion was 60° (±14°); wrist extension was 45° (±21°)., Conclusions: Clinical outcomes proved more favorable than anticipated, particularly the self-rated outcomes scores and the absence of any revision or conversion surgery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Steroid-induced avascular necrosis (AVN) of the lower extremity is a destructive process of the bone found in patients who have been treated with these medications for a variety of medical conditions. There are several proposed etiologies for development of this condition, however much debate still remains for the exact pathophysiology. The main clinical characteristics include edema, arthralgias, and restricted joint range of motion. Diagnostic imaging is a key aspect in the analysis of this pathologic process. When steroid-induced AVN affects multiple bones, this atypical presentation is difficult to treat due to its diffuse nature, therefore surgical options are limited. In these cases, conservative therapy is targeted toward pain relief and preserving joint range of motion. This review aims to provide an overview on the presentation of steroid-induced AVN in the foot and ankle, outline the pathophysiology of the process, and describe a variety of both conservative and surgical treatment options. A case study is provided to showcase a patient presentation of diffuse steroid-induced AVN of the foot and ankle and their course of treatment. Levels of Evidence: Level V: Expert opinion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Although various studies have proposed vascular and mechanical factors, the etiology of Kienböck disease is unknown. Kienböck theorized that lunatomalacia resulted from traumatic disruption of blood supply and bony nutrition to the lunate. Extraosseous supply to the lunate, as far as volar or dorsal vessels are concerned, is still controversial. This study evaluated the extraosseous nutrient foramina from the dorsal and volar aspects of lunate specimens. A total of 913 specimens from the Hamann-Todd Osteological Collection in Cleveland, Ohio, were examined. The nutrient artery foramina on left and right lunate specimens were examined from dorsal and volar aspects. The number of nutrient artery foramen was tabulated. Age, sex, and race data were collected. Specimens were divided into groups according to the number of nutrient artery foramina, and the dorsal and volar foramina were compared. The average number of foramina on the dorsal aspect of the lunate (1.71) was greater than the volar aspect (1.64), except in specimens younger than 35 years. A greater number of specimens had 3 or more foramina on the dorsal side compared with the volar aspect. Based on this study, there was significant contribution of dorsal arterial vessels to the blood supply of lunate specimens older than 35 years, which contrasts with findings in earlier studies. The disruption of dorsal intercarpal and radiocarpal ligaments leading to the disruption of the dorsal arterial arches may contribute to vascular insufficiency of the lunate and should be evaluated further in the etiopathogenesis of Kienböck disease. [ Orthopedics . 2021;44(2):e243-e247.].

Background: Half of osteonecrosis of the femoral head (ONFH) patients suffer femoral head collapse at initial diagnosis, and more than half are bilaterally affected. This study developed a percutaneous autologous impaction bone graft (IBG) technique as a modification of core decompression (CD). We also summarized the short-term results and treatment efficacy of percutaneous autologous IBG in advanced ONFH., Methods: Twenty patients (12 males, 8 females) with nontraumatic, postcollapse ONFH except one case underwent CD (10-mm core diameter) and reverse IBG. Radiological changes of the ONFH stage and type were analyzed. Survival analysis using Kaplan-Meier estimates was performed with conversion to total hip arthroplasty (THA) as the endpoint. In addition, the Harris hip score (HHS) and University of California, Los Angeles (UCLA) activity rating scale were evaluated., Results: Percutaneous autologous IBG was performed successfully, with an average operation time of < 1 h and small blood loss, and 7 patients (35%) needed conversion to THA at an average of 17 months postoperatively. We observed radiological progressive change in 60% of the patients during a mean observation period of 3 years. The mean clinical scores, except data recorded, after THA significantly improved (before vs. after 3 years: UCLA activity score, 3.7 vs. 5.2 [P = 0.014]; HHS, 57.6 vs. 76.5 points [P = 0.005]). In addition, 6 patients showed radiological progression but no clinical deterioration., Conclusions: Percutaneous autologous IBG was technically simple and minimally invasive, but short-term results were unsatisfactory for advanced ONFH. Indications for this procedure should be carefully examined to improve it in order to enable bone formation.

Background: This retrospective study aimed to describe the techniques and results of distal metatarsal segmental shortening (DMSS) for the treatment of chronic irreducible metatarsophalangeal (MTP) dislocation of lesser toes., Methods: We retrospectively reviewed patients who underwent DMSS for chronic dislocation of MTP joints of lesser toes between January 2010 and December 2017 with follow-up of at least 24 months. Demographic data, radiographic measurements, functional outcomes, and complications were analyzed. Furthermore, the results of patients with short segment of shortening (group I, <10 mm) were compared to those with long segment of shortening (group II, ≥10 mm). A total of 43 MTP joints of 30 patients with an average age of 70.4 years were included., Results: Union was observed in 42 metatarsals (97.7%). Mean American Orthopaedic Foot & Ankle Society scale scores improved significantly from 42.2 (range, 15-65) preoperatively to 79.1 (range, 52-90) ( P < .001). Mean visual analog scale pain score improved significantly from 5.0 (range, 1-9) preoperatively to 1.8 (range, 0-6) ( P < .001). Complications included 1 nonunion, 1 osteonecrosis, 3 metatarsal angulation, 4 recurrent instability, 4 symptomatic osteoarthritis, 3 transfer metatarsalgia, and 1 floating toe. Group I included 23 MTP joints and group II included 20 MTP joints. There was no significant difference in clinical outcomes and complications between the 2 groups., Conclusion: DMSS was a reliable procedure for the treatment of chronic irreducible dislocated MTP joint of lesser toes. It provided satisfactory surgical outcomes and a low rate of postoperative complications, regardless of length of metatarsal shortening., Level of Evidence: Level III, retrospective comparative study.

Traumatic osteonecrosis of femoral head (TONFH) is a common orthopedic disease caused by physical injury in hip. However, the unclear pathogenesis mechanism of TONFH and lacking of simple noninvasive early diagnosis method cause the necessity of hip replacement for most patients with TONFH. In this study, we aimed to identify circulating microRNAs (miRNAs) by integrated bioinformatics analyses as potential biomarker of TONFH. mRNA expression profiles were downloaded from the Gene Expression Omnibus database. Then we combined two miRNA screen methods: Weighted gene co-expression network analysis and fold change based differentially expressed miRNAs analysis. As a result, we identified 14 key miRNAs as potential biomarkers for TONFH. Besides, 302 target genes of these miRNAs were obtained and the miRNA-mRNA interaction network was constructed. Furthermore, the results of Kyoto Encyclopedia of Gene and Genome pathway analysis, Gene Ontology function analysis, protein-protein interaction (PPI) network analysis and PPI network module analysis showed close correlation between these 14 key miRNAs and TONFH. Then we established receiver operating characteristic curves and identified 6-miRNA signature with highly diagnosis value including miR-93-5p (area under the curve [AUC] = 0.93), miR-1324 (AUC = 0.92), miR-4666a-3p (AUC = 0.92), miR-5011-3p (AUC = 0.92), and miR-320a (AUC = 0.89), miR-185-5p (AUC = 0.89). Finally, the results of quantitative real-time polymerase chain reaction confirmed the significantly higher expression of miR-93-5p and miR-320a in the serum of patients with ONFH. These circulating miRNAs could serve as candidate early diagnosis markers and potential treatment targets of TONFH., (© 2020 Wiley Periodicals, Inc.)

Background: Patients with talar avascular necrosis (AVN) have limited treatment options to manage their symptoms. Historically, surgical options have been limited and can leave patients with little ankle motion and have high failure rates. The use of custom 3D printed total talar replacements (TTRs) has arisen as a treatment option for these patients, possibly allowing better preservation of hindfoot motion. We hypothesized that patients undergoing TTR will demonstrate a statistically significant improvement in Foot and Ankle Outcome Score (FAOS) at 1 year after surgery., Methods: We retrospectively reviewed 15 patients who underwent a TTR over a 2-year period. Patient outcomes were reviewed, including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, radiographic alignment, FAOS and Visual Analog Scale (VAS) score, and range of motion. Data analysis was performed with Student t-tests and multivariate regression., Results: FAOSs and VAS scores showed statistically significant improvements postoperatively as compared with preoperative scores. There was a statistically significant decrease in VAS pain scores from 7.0 preoperatively to 3.6 (P < .001). Average follow-up was 12.8 months. With the number of patients available, there was no statistically significant change in radiographic alignment parameters postoperatively as compared with preoperatively (P values ranged from .225 to .617)., Conclusion: Our hypothesis that these patients show statistically significant improvements in FAOSs at 1 year was confirmed. TTR represents an exciting treatment option for patients with talar AVN, though longer-term follow-up is needed. Level of Evidence: Level IV: Case series.

Background: One of most accepted principles for treating Kienböck's disease before wrist degeneration settles in is to decompress the lunate by an osteotomy. Several osteotomies have been proposed since 1935. However, they are based on biomechanical hypotheses that are sometimes conflicting: This study compares the decompression effect of radius transverse shortening, radius lateral closing and medial closing wedge osteotomies, capitate shortening - with and without hamate shortening - and a Camembert-type radius wedge osteotomy with and without ulnar head shortening according to Sennwald., Methods: We built a 3D wrist model using finite elements that included the metacarpal, carpal and forearm bones. All wrist ligaments and Triangular Fibrocartilage Complex were incorporated in the simulation. Load was applied on the metacarpals with the forearm bones fixed. We then applied the different osteotomies to the model., Findings: When load was applied to the wrist, the osteotomies that best unloaded the lunate were the capitate shortening osteotomy combined with hamate shortening and the Camembert osteotomy combined with ulna shortening; the latter was the only osteotomy that completely unloaded the lunate., Interpretation: We think the association of the radius Camembert osteotomy and ulna Sennwald's shortening osteotomy is the most effective procedure to propose in Kienböck's disease., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: In recent years, percutaneous vertebroplasty (PVP) has provided a new option for the treatment of Kümmell's disease (KD). This retrospective study aimed to investigate the differences in clinical characteristics, clinical efficacy, and related complications between two types of bone cement distribution patterns in the PVP treatment of KD., Methods: A total of 63 patients with KD from January 2016 to February 2018 who received PVP treatment were examined at least 24 months. According to X-ray distribution modes of bone cement after PVP treatment, they were divided into 2 groups: blocky group (30 cases) and spongy group (33 cases). Clinical features and disease severity preoperatively, and clinical efficacy and related complications postoperatively were statistically compared between the two groups., Results: The two groups were followed for at least 24 months. The duration of disease, age, Cobb angle, and vertebral compression rate preoperatively were significantly higher in the blocky group than in the spongy group (P < 0.05, respectively). The height of vertebral anterior margin and BMD were significantly lower in the blocky group than in the spongy group (P < 0.05, respectively). The amount of bone cement injected was significantly greater in the blocky group than in the spongy group (P = 0.000). VAS and ODI of the two groups were significantly reduced at the first day, the first year, and the last follow-up postoperatively (all P = 0.000) and were maintained at the last follow-up. VAS and ODI postoperatively decreased significantly in the spongy group compared with the blocky group (P = 0.000). The correction degrees of kyphosis and vertebral compression postoperatively in the two groups were significantly corrected, but gradually decreased over time (P < 0.05), and these correction degrees were significantly higher in the blocky group than in the spongy group, and the postoperative losses were also more serious., Conclusions: The disease was more serious in the blocky group than in the spongy group. The amount of bone cement, correction degrees of postoperative kyphosis and vertebral compression were significantly higher in the blocky group than in the spongy group, but its postoperative losses of the correction degrees of kyphosis and vertebral compression were also more serious. However, for pain relief and functional recovery, the spongy group was superior to the blocky group. Therefore, the spongy distribution pattern should be formed during the injection of bone cement to obtain better therapeutic effect.

Background: Appropriate postoperative lower limb alignment is one important element of a successful unicompartmental knee arthroplasty (UKA). To predict postoperative alignment, it is important to investigate the association between preoperative imaging evaluations and lower limb alignment after medial UKA., Questions/purposes: (1) Do preoperative valgus stress radiographic and MRI measurements (% mechanical axis, hip-knee-ankle angle, medial meniscal extrusion distance, and osteophyte area at the medial femur and tibia) correlate with postoperative lower limb alignment after UKA; and (2) Can useful cutoffs be calculated in advance of surgery for those findings that were associated with coronal-plane overcorrection?, Methods: We retrospectively analyzed 125 patients with medial knee pain who underwent UKA from January 2012 to October 2018. Valgus stress radiography and MRI were performed routinely to assess the knee. Valgus stress radiography was obtained with the patient supine with the knee in full extension and a firm manual valgus force applied to the knee. Full-length weightbearing radiography was performed 3 months after surgery. There were 12% (15) of patients who did not undergo MRI, and 4% (five) of patients who did not receive the postoperative full-length weightbearing radiograph and they were excluded, leaving 84% (105) of patients available for analysis. There were 27 men and 78 women with a mean (range) age of 77 years ± 6 years (60 to 87). The preoperative diagnosis was medial osteoarthritis in 99 patients and osteonecrosis of the medial femoral condyle in six. To investigate the associations, we routinely measured % mechanical axis using radiography, and also measured the medial meniscal extrusion distance and osteophyte area at the medial femur and tibia using MRI after surgery. Medial meniscus extrusion distance was defined as the distance from the outermost edge of the medial meniscus to a line connecting the femoral and tibial cortices. From these parameters, postoperative alignment was estimated using regression and receiver operating characteristic curve analyses. Variables with p < 0.05 were included., Results: The % mechanical axis on the valgus stress radiograph and medial meniscal extrusion distance were correlated with postoperative lower limb alignment after UKA (adjusted correlation coefficient 0.72; p < 0.001, adjusted correlation coefficient 0.2; p = 0.003, respectively). The estimated % mechanical axis on the postoperative weightbearing radiograph was equal to -0.27 + 0.86% (% mechanical axis on valgus stress radiograph) + 1.14 mm (medial meniscal extrusion distance). Using a cutoff point of 36%, the % mechanical axis on valgus stress radiograph was associated with overcorrection after UKA (area under the curve: 0.89; odds ratio 14 [95% CI 0.75 to 0.95]; p < 0.001, sensitivity 77.8%, specificity 80.9%)., Conclusions: The overcorrection of a varus knee on a valgus stress radiograph before UKA and the increased extrusion of the medial meniscus on preoperative MRI was associated with a greater likelihood of overcorrected alignment after UKA. Future studies should conduct long-term follow-up of malalignment patients to assess the possible complications., Level of Evidence: Level III, diagnostic study.

Introduction: In sickle cell disease (SCD), hemoglobin S (HbS) red blood cells (RBCs) are characteristically deformed and inflexible. Often breaking down in the circulation, they exhibit increased adhesive properties with the endothelium and activated neutrophils and platelets, increasing the risk of occlusion of the microcirculation. SCD is categorized into two sub-phenotypes: hyperhemolytic, associated with priapism, leg ulcers, pulmonary hypertension, and stroke, and high hemoglobin/viscosity, which may promote vaso-occlusion-associated pain, acute chest syndrome, and osteonecrosis., Areas Covered: The sub-phenotypes are not completely distinct. Hemolysis may trigger vaso-occlusion, contributing to vascular complications. Targeting P-selectin, a key mediator of cross-talk between hyperhemolysis and vaso-occlusion, may be beneficial for vascular and vaso-occlusion-associated complications. English-language articles from PubMed on the topic of SCD and vaso-occlusive crises (VOCs) were reviewed from 1 January 2000 to 1 January 2019 using the search terms 'sickle cell disease,' 'vaso-occlusive crises,' and 'selectin.', Expert Opinion: Besides targeting P-selectin, other strategies to counter VOCs and RBC sickling are being pursued. These include platelet inhibition to counter aggregation, intercellular adhesion, and thrombosis during VOCs; gene therapy to correct the homozygous missense mutation in the β-globin gene, causing polymerization of HbS; L-glutamine, possibly reducing oxidative stress in sickled RBCs; and fetal hemoglobin inducers.

Purpose: The study aimed to evaluate the optimal timing for plate removal after open-wedge high tibial osteotomy (OWHTO) without loss of correction and to investigate risk factors for loss of correction after plate removal. The study presents the hypothesis that plate removal without loss of correction was possible when gap filling reached zone 2 (25-50%) on anteroposterior radiographs., Methods: Ninety-one patients (101 knees) who underwent OWHTO using the TomoFix ® plate were enrolled. Plate removal was performed at an average 16.4 ± 5.4 months after OWHTO. Clinical evaluation included plate-related symptoms, the Japanese Orthopedic Association Knee Score (JOA score), and Oxford Knee Score (OKS). Radiological outcomes, including the hip-knee-ankle angle (HKA), weight-bearing line ratio (WBLR), medial proximal tibial angle (MPTA), and posterior tibial slope (PTS), were evaluated preoperatively, at plate removal and at 1 year after plate removal. Computed tomography (CT) was performed at plate removal to evaluate the flange bone union, progression rates of gap filling, and posterior cortex bone union. In addition, the risk factors for loss of correction after plate removal were evaluated., Results: At plate removal, 63 (62.4%) knees had plate-related symptoms (mild, 56 knees; moderate, 7 knees; severe, 0). After plate removal, the JOA score did not change, whereas OKS further improved; six knees developed loss of correction. On CT evaluation at plate removal, the flange bone union was achieved in all cases; the progression rates of gap filling and posterior cortex bone union were 47.0% ± 16.6% and 62.8% ± 16.5%, respectively. A posterior cortex union rate of < 43.3% was the only predictor for loss of correction after plate removal (odds ratio: 1.38, P < 0.01)., Conclusions: Plate removal without loss of correction after OWHTO was possible when bone union of the posterior cortex reached the center of the osteotomy gap even in incompletely filled gaps., Level of Evidence: Therapeutic case series, Level IV.

Background: It is unclear whether lunate fracture types in Kienböck disease correlate with the degree of fracture healing. This study aimed to review the clinical results of stage 3 Kienböck disease treated using partial capitate shortening (PCS) and to evaluate the healing rates of lunate fractures based on the fracture types., Methods: Twenty-three patients were clinically and radiographically followed up for >2 years after PCS. The preoperative location and postoperative healing of the lunate fracture were evaluated using plain radiography, computed tomography, and/or magnetic resonance imaging. Results were evaluated using the Kienböck scoring system by Nakamura., Results: PCS was clinically effective, demonstrating excellent and good results in 11 and 11 patients, respectively. Pain evaluated using the visual analog scale, wrist extension, flexion motion, and grip strength significantly improved postoperatively (p < 0.01). Fractures were preoperatively detected in all 23 cases. Fracture locations were preoperatively classified into five subtypes based on radiographs: volar pole in five patients, dorsal pole in three, coronal in five, transverse in nine, and ulnar in one. The overall union rate of the lunate fracture was 48%, whereas none of the coronal fractures healed., Conclusions: PCS was effective in treating stage 3 Kienböck disease. Coronal lunate fractures had a poor healing rate relative to those of the other fracture types., Study Design: Clinical, retrospective study., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Femoral head collapse is the key to the progress of osteonecrosis of the femoral head (ONFH), but the causes of collapse are not completely clear. The better understanding of the progress of femoral head collapse will guide the treatment strategy for ONFH patients. The purpose of this study was to evaluate the biomechanical influence of necrosis area on the collapse of the femoral head by finite element analysis., Methods: CT and MRI data from the hip joint of a healthy volunteer were collected to establish a finite element (FE) model of a normal hip. Subsequently, five categories of osteonecrosis FE models were established by using the normal model and computer software according to China-Japan Friendship Hospital (CJFH) classification for ONFH. The CJFH system includes five types based on the size and location of necrosis lesions in the femoral head (type M, C, L1, L2, and L3) and the stage of ONFH. The collapse indices of each model were analyzed by FE method, including the displacement, peak von Mises stress and stress index of the simulated necrotic area as well as the lateral pillar contact area of the femoral head to acetabular., Results: (1) The displacement increments in the simulated necrotic areas of type M, C, L1, L2, and L3 models were 3.75 μm, 8.24 μm, 8.47 μm, 18.42 μm, and 20.44 μm respectively; the peak von Mises stress decrements were 1.50 MPa, 3.74 MPa, 3.73 MPa, 4.91 MPa, and 4.92 MPa respectively; and the stress indices were 0.04, 0.08, 0.08, 0.27, and 0.27 respectively. (2) The displacement increments in the lateral pillar contact areas of five type models were significantly different (P < 0.001) and increased in sequence as follows: 1.93 ± 0.15 μm, 5.74 ± 0.92 μm, 5.84 ± 1.42 μm, 14.50 ± 3.00 μm, and 16.43 ± 3.05 μm. The peak von Mises stress decrements were also significantly different (P < 0.001) and increased in sequence as follows: 0.52 ± 0.30 MPa, 0.55 ± 0.12 MPa, 0.67 ± 0.33 MPa, 4.17 ± 0.59 MPa, and 4.19 ± 0.60 MPa. (3) The collapse indices including the displacement increments and peak von Mises stress decrements of type L2 and L3 models were markedly higher than those of type M, C, and L1 models (P < 0.001)., Conclusions: The collapse indices of the femoral heads of type L2 and L3 FE models were significantly higher than those of type M, C, and L1. Different areas of necrosis result in varied impact on the femoral head collapse.

Background: Glucocorticoids used to treat childhood leukemia and lymphoma can result in osteonecrosis, leading to physical dysfunction and pain. Improving survival rates warrants research into long-term outcomes among this population., Objective: The objective of this study was to compare the physical function and quality of life (QOL) of survivors of childhood cancer who had an osteonecrosis history with that of survivors who had no osteonecrosis history and with that of people who were healthy (controls)., Design: This was a cross-sectional study., Methods: This study included St Jude Lifetime Cohort Study participants who were ≥ 10 years from the diagnosis of childhood leukemia or lymphoma and ≥ 18 years old; 135 had osteonecrosis (52.5% men; mean age = 27.7 [SD = 6.08] years) and 1560 had no osteonecrosis history (52.4% men; mean age = 33.3 [SD = 8.54] years). This study also included 272 people who were from the community and who were healthy (community controls) (47.7% men; mean age = 35.1 [SD = 10.46] years). The participants completed functional assessments and questionnaires about QOL., Results: Survivors with osteonecrosis scored lower than other survivors and controls for dorsiflexion strength (mean score = 16.50 [SD = 7.91] vs 24.17 [SD = 8.61] N·m/kg) and scored lower than controls for flexibility with the sit-and-reach test (20.61 [SD = 9.70] vs 23.96 [SD = 10.73] cm), function on the Physical Performance Test (mean score = 22.73 [SD = 2.05] vs 23.58 [SD = 0.88]), and mobility on the Timed "Up & Go" Test (5.66 [SD = 2.25] vs 5.12 [SD = 1.28] seconds). Survivors with hip osteonecrosis requiring surgery scored lower than survivors without osteonecrosis for dorsiflexion strength (13.75 [SD = 8.82] vs 18.48 [SD = 9.04] N·m/kg), flexibility (15.79 [SD = 8.93] vs 20.37 [SD = 10.14] cm), and endurance on the 6-minute walk test (523.50 [SD = 103.00] vs 572.10 [SD = 102.40] m)., Limitations: Because some eligible survivors declined to participate, possible selection bias was a limitation of this study., Conclusions: Survivors of childhood leukemia and lymphoma with and without osteonecrosis demonstrated impaired physical performance and reported reduced QOL compared with controls, with those requiring surgery for osteonecrosis most at risk for impairments. It may be beneficial to provide strengthening, flexibility, and endurance interventions for patients who have pediatric cancer and osteonecrosis for long-term function., (© 2020 American Physical Therapy Association.)

One of the most important aspects of bone remodeling is the constant turnover mainly driven by the mechanical loading stimulus. The remodeling process produces changes not only in the bone microarchitecture but also in the density distribution of the mineralized matrix - i.e. in calcium concentrations- and in the osteocyte lacunar network. Synchrotron radiation-based X-ray microtomography (microCT) has proven to be an efficient technique, capable to achieve the analysis of 3D bone architecture and of local mineralization at different hierarchical length scales, including the imaging of the lacuno-canalicular network. In the present study, we used microCT within a conceptual study of jawbone remodeling, demonstratively focusing the investigation in two critical contexts, namely in the peri-dental and the peri-implant tissues. The microCT analysis showed that a relevant inhomogeneity was clearly present in both peri-dental and peri-implant biopsies, not only in terms of microarchitecture and mineralization degree, but also considering the lacunar network, i.e. size and numerical density of the osteocyte lacunae. The correlated histological results obtained on the same samples confirmed these observations, also adding information related to non-mineralized tissues. Despite its demonstrative nature, it was concluded that the proposed method was powerful in studying jawbone remodeling because it revealed a direct correlation of its rate with the lacunar density, as achieved by the analysis of the osteocyte lacunar network, and an inverse correlation with the local bone mineral density, as revealed with the Roschger approach.

There have been many reports on the clinical outcomes of Oxford unicompartmental knee arthroplasty (UKA); however, none have investigated the influence of flexion angle after UKA on clinical outcomes. The objective of this study was to clarify the relationship between outcomes and the postoperative maximum flexion angle and reveal the necessary factors for maximum flexion angle ≥ 140 degrees which is considered necessary for Asian populations. We categorized 212 UKA patients into the following three groups based on the postoperative maximum flexion angle: group 1 had flexion angle ≥ 140 degrees in 80 patients (38%), group 2 had 130 degrees ≤ flexion angle < 140 degrees in 80 patients (38%), and group 3 had flexion angle < 130 degrees in 52 patients (24%). Furthermore, we compared the postoperative clinical outcomes between the three groups and conducted multivariable regression analyses to assess parameters affecting the flexion angle. Postoperative Knee Society function scores for group 1 was significantly higher than for group 3. Group 1 had higher mean knee injury and osteoarthritis outcome scores (KOOS) in all subscales and significantly higher KOOS scores in the sports and quality of life subscales compared with group 2 and in all subscales compared with group 3. Multivariable logistic regression showed that preoperative flexion angle and tibial component posterior slope were associated with maximum flexion angle ≥ 140 degrees. Maximum flexion angle ≥ 140 degrees after Oxford UKA improved the clinical results, particularly for patient-reported outcomes. Furthermore, the tibial posterior slope was an important factor in achieving maximum flexion angle ≥ 140 degrees in UKA patients., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

In this study, we aimed to identify a candidate drug that can activate endogenous Angiopoietin 1 (Ang1) expression via drug repositioning as a pharmacological treatment for avascular osteonecrosis. After incubation with 821 drugs from the Food and Drug Administration (FDA)-approved drug library, Ang1 expression in U2OS cell culture media was examined by ELISA. Metformin, the first-line medication for treatment of type 2 diabetes, was selected as a candidate for in vitro and in vivo experimental evaluation. Ang1 was induced, and alkaline phosphatase activity was increased by metformin treatment in U2OS and MG63 cells. Wound healing and migration assay showed increased osteoblastic cell mobility by metformin treatment in U2OS and MG63 cells. Metformin upregulated expression of protein markers for osteoblastic differentiation in U2OS and MG63 cells but inhibited osteoclastic differentiation in Raw264.7 cells. Metformin (25 mg/kg) protected against ischemic necrosis in the epiphysis of the rat femoral head by maintaining osteoblast/osteocyte function and vascular density but inhibiting osteoclast activity in the necrotic femoral head. These findings provide novel insight into the specific biomarkers that are targeted and regulated by metformin in osteoblast differentiation and contribute to understanding the effects of these FDA-approved small-molecule drugs as novel therapeutics for ischemic osteonecrosis.

Aims: The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up., Patients and Methods: A total of 31 patients with a mean age of 54 years (27 to 73) were analyzed; nine had primary osteoarthritis (OA) and 17 had post-traumatic OA, three had capitellar osteonecrosis, and two had a fracture. Overall, 17 Lateral Resurfacing Elbow (LRE) and 14 Uni-Elbow Radio-Capitellum Implant (UNI-E) arthroplasties were performed. Pre- and postoperative assessment involved the Mayo Elbow Performance Score (MEPS), the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the modified American Shoulder Elbow Surgeons (m-ASES) score., Results: The mean follow-up was 6.8 years (3.8 to 11.5). The mean MEPS, m-ASES, and Q-DASH scores improved significantly by 50 (p < 0.001), 55 (p < 0.001), and 54 points (p < 0.001), respectively, with no differences being detected between the implants. Preoperative pronation and supination were worse in patients in whom the UNI-E was used. Two patients with the UNI-E implant had asymptomatic evidence of gross loosening., Conclusion: Radiocapitellar arthroplasty yielded a significant improvement in elbow function at a mean follow-up of 6.8 years, with a high implant survival rate when the LRE was used in patients with primary or post-traumatic OA, without radial head deformity, and when the UNI-E was used in patients in whom radial head excision was indicated. Cite this article: Bone Joint J 2019;101-B:1362-1369.

We evaluated the outcomes of the Re-motion total wrist arthroplasty in 39 non-rheumatoid patients. The mean follow-up was 7 years (range 3-12). Postoperative wrist flexion-extension and radial-ulnar deviation as well as the scores of the Disability of Arm Shoulder and Hand questionnaire and the visual analogue scale pain scores improved significantly. Complications occurred in 13 wrists, five of which required further surgery. The most frequent complication was impingement between the scaphoid and the radial implant (n = 5), which can be avoided by complete or almost complete scaphoid resection. Periprosthetic radiolucency developed around the radial component in three cases and three radial screws loosened. Despite the incidence of high implant survival in 38 of 39 wrists over 7 years (97%), the complication rate is not satisfying. Knowledge of the risk of complications and patient selection are essential when making the decision to choose wrist arthroplasty over arthrodesis. Level of evidence: IV.

Background: Unicompartmental knee arthroplasty (UKA) is an option for the treatment of spontaneous osteonecrosis of the knee (SONK). However, there are limited studies focusing on this area. This study presents medium-term clinical outcome data of UKA for SONK., Methods: We reviewed 50 SONK knees in 48 patients that were treated by UKA. The mean age, height, and body weight were 73 years, 153 cm, and 57 kg, respectively. The mean follow-up was 8.4 years (range, four to 15 years). Preoperatively, we measured the size and the volume (estimated by width × length × depth) of the necrotic bone mass on T1-weighted magnetic resonance imaging. The clinical results were evaluated serially at follow-up visits radiographically and with the Knee Society Scoring (KSS) and Oxford Knee Scoring (OKS) systems., Results: There were no revisions, re-operations, or major complications. The mean sizes of the necrotic lesions were 17.2 mm (14.7-22.3 mm) in width, 28.2 mm (6.2-34.7 mm) in length, and 11.3 mm (3.2-14.5 mm) in depth. The mean volume was approximately 5.4 cm 3 (0.7-10.3 cm 3 ). The mean flexion of the knee, KSS Knee Score, Function Score, and OKS increased from a preoperative 128.7-137.5°, 52.3-91.3, 39.7-90.2, and 21.6-40.2, respectively, at the latest follow-up. At the last follow-up, all patients had good or excellent OKS., Conclusions: This study demonstrates that UKA is a good option and is reliable for the treatment of SONK irrespective of necrotic bone mass size., (Copyright © 2019. Published by Elsevier B.V.)

Objectives: This study aims to clinically evaluate the efficacy of pedicle bone flap treatment in stage II Kienböck's disease., Patients and Methods: This retrospective study included 10 patients (8 males, 2 females; mean age 33.3 years; range, 23 to 46 years) treated with pedicle bone flap between January 2012 and June 2016. In all patients, a fourth extensor compartment artery (ECA) pedicle bone flap from the dorsal surface of the radius was prepared and placed through a window opened on the lunate bone. Clinical results of the patients were evaluated according to the Mayo wrist score., Results: All patients could return to their daily activities after surgery. No superficial or deep infection developed requiring debridement or antibiotic use other than prophylaxis. None of the patients required reoperation due to complications or the progression of the disease. The mean Mayo wrist score was measured as 81 (good)., Conclusion: In this study, results of the fourth ECA pedicle bone flap application were found to be effective in the treatment of avascular necrosis of the lunate bone. Further comparative and long-term follow-up studies are required including large and homogeneous patient groups.

Rationale: Kashin-Beck disease (KBD) is known for some typical characters like finger joint enlargement, shortened fingers, and dwarfism. However, Avascular necrosis (AVN) of the talus in KBD has rarely been reported in the literature. Here, we reported on a KBD patient presented with partial AVN of the talus in conjunction with ankle and subtalar arthritis., Patient Concerns: A 50-year-old woman presented with severe pain and limited range of motion in her left ankle and subtalar joint while walking for 2 years. She had been walking with the aid of crutches for many years. Conservative treatment with rigid orthosis and activity restriction could not help reduce the pain in the left foot., Diagnoses: Radiographs demonstrated that partial AVN was developed in the body of the talus and arthritis was viewed in the left ankle and subtalar joint. Hence, we established the diagnosis of partial talar AVN in conjunction with ankle and subtalar arthritis., Interventions: A conservative tibiotalocalcaneal fusion attempting to preserve as much viable talar body as possible was performed using a humeral locking plate and 2 cannulated compression screws., Outcomes: Bone union proved by CT scan and a good alignment of the left limb were achieved at 4-month follow-up postoperatively., Lessons: Partial AVN of the talus along with ankle and subtalar arthritis in KBD patients has rarely been reported as it is not a common characteristic of KBD in clinical practice. Conservative tibiotalocalcaneal fusion could help preserving much more viable talar body, maintaining most structural integrity of the ankle joint, and achieving a stable and plantigrade foot postoperatively.

Purpose: Osteonecrosis of the jaw (ONJ), both medication-related and non medication-related, mainly occurs in aged patients. It needs surgical intervention. Refractory healing after an operation of ONJ can significantly lower the quality of life of elderly patients. The purpose of this study was to determine risk factors associated with refractory healing in aged patients. Patients and methods: We performed a retrospective study of ONJ in aged patients who underwent surgical treatments in a single institute during a 12-year period. Multiple logistic regression analysis was used to determine independent risk factors associated with refractory healing. Results: A total of 122 patients were included. Of them, 25 patients were identified as the refractory group and 97 patients as the control group. Diabetes mellitus (DM) (AOR=5.03, 95% CI: 1.74-14.52) and glucocorticoid administration (AOR=7.97, 95% CI: 2.52-25.23) were found to be significant risk factors for refractory healing of ONJ. Conclusion: DM and medication of glucocorticoid might be risk factors for refractory healing of ONJ., Competing Interests: The authors report no conflicts of interest in this work.

Raine syndrome is characterized by FGF23-mediated hypophosphatemic osteomalacia with osteosclerosis caused by mutations in the FAM20C gene. We report a case of a 72-year-old man who presented with rapid progressive spontaneous osteonecrosis of the knee (SONK). A full osteologic assessment including dual energy X-ray absorptiometry (DXA), high-resolution peripheral quantitative computed tomography (HR-pQCT), and serum analyses revealed a high bone mass in the lumbar spine and hip (DXA T-score + 7.5 and + 4.7/+4.2) with increased bone microstructural parameters in the distal radius and tibia (BV/TV 127%, 140% of the age-matched mean, respectively), as well as a low bone turnover state. Phosphate levels were low due to renal phosphate wasting and high FGF23 levels (126.5 pg/ml, reference range 23.2-95.4 pg/ml). Using gene panel sequencing, we identified a novel FAM20C heterozygous missense mutation in combination with a homozygous duplication that potentially alters splicing. Taken together, this is the first case of mild Raine syndrome with spontaneous osteonecrosis of the knee, phosphate wasting, and a pronounced trabecular high bone mass phenotype.

Background: Osteonecrosis of the hips and knees is an often debilitating adverse event in children treated with glucocorticoids for leukemia and lymphoma but the impact of shoulder involvement has been understudied. Thus, we investigated the severity and functional impairment of shoulder osteonecrosis in a well-characterized population of pediatric patients treated for acute lymphoblastic leukemia or lymphoma., Methods: We retrospectively reviewed orthopaedic clinic and physical therapy evaluations to determine range of motion (ROM), pain, and impact of magnetic resonance-defined osteonecrosis (ON) on activities of daily living. Adverse events were classified according to the National Cancer Institute's Common Terminology Criteria for Adverse Events version 4.03., Results: We identified 35 patients (22 female), median age at cancer diagnosis 14.2 (range, 4.3 to 19) years; median age at ON diagnosis 16.7 (range, 5.5 to 28) years. Median time to last follow-up from diagnosis of primary malignancy was 6.4 (range, 0 to 12.7) years and from diagnosis of ON was 4.0 (range, 0 to 8.9) years. Twenty-two patients had magnetic resonance evidence of ON; 43 shoulders involved at least 30% of the articular surface of the capital humeral epiphyses.Common Terminology Criteria for Adverse Events mean scores for initial assessments of 55 shoulders (29 patients) showed moderate negative impact of ON on activity of daily living (1.94), decreased ROM limiting athletic activity (0.98), and mild to moderate levels of pain (1.38). Analysis of this group's most recent assessment showed improvement in pain and ON over time, with an average pain grade of 0.58 indicating no pain to mild pain, and 1.37 for ON grade, indicating asymptomatic to mildly symptomatic impact on activities of daily living. We also found minimal worsening average ROM grades (1.11)., Conclusions: Shoulder ON is an underappreciated adverse late effect of therapy in children treated for leukemia/lymphoma which can limit quality of life and functionality. In most cases, pain and disability can be improved with treatment., Level of Evidence: Level IV-case series.

Background: MicroRNAs have recently been recognized to be engaged in the development of bone diseases., Objective: This study was performed to elucidate the effects of miR-144-3p on proliferation and osteogenesis of mesenchymal stem cells (MSCs) from the patients with steroid-associated osteonecrosis (ONFH) and its related mechanism., Method: The expression level of miR-144-3p in the MSCs from the proximal femur of the patients was examined by Real-time PCR. The cell proliferation ability was assayed by MTT. The differentiation ability of MSCs was assayed by Alizarin Red S (ARS) staining. The interaction between miR-144-3p and frizzled4 (FZD4) was investigated by Real-time PCR, western blot and luciferase reporter assay., Results: ONFH samples had the obviously high expression of miR-144-3p compared to the control. MiR-144-3p had a negative effect on the proliferation and osteogenesis of MSCs. Via targeting FZD4, miR-144-3p decreased β-catenin nuclear translocation, the transcription of RUNX2 and COL1A1. Over-expression of FZD4 partially reversed miR-144-3p-induced decrease in the proliferation and osteogenesis of MSCs., Conclusion: MiR-144-3p might play an important role in the development of ONFH and might be used as a novel class of therapeutic targets for this disease., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Purpose: Primary Spontaneous osteonecrosis of the knee (SPONK) was a result of a subchondral insufficiency fracture based on histopathological examinations. There were few studies examining patients who underwent unicompartmental knee arthroplasty (UKA) for the treatment of primary SPONK. The aim of this study was to investigate (1) patient-reported outcome measure (PROM), (2) survivorship of revision as end point and (3) survivorship of complication as end point in patients with primary SPONK., Methods: The clinical examinations of a consecutive series of 61 medial UKAs for primary SPONK of the medial femoral condyle from 2008 to 2012 were evaluated retrospectively at our institution. There were 18 males and 43 females with a mean age of 73.7 years (60-91). In all patients, preoperative radiographs were analyzed according to the stage of primary SPONK. We conducted Kaplan-Meier survival analyses using revision and complications for any reasons as the end point., Results: Mean follow-up was 6.6 years (range 6-10). UKA using Physica ZUK (LIMA Corporate. UD, Italy) for SPONK improved patients' 2011 Knee Society symptom score, patient satisfaction, patient activities, EQ-5D and postoperative ranges of motion compared with their preoperative status (P < 0.01). Revision surgery was required in one knee (1.6%) due to postoperative fracture of the medial tibial plateau after a fall that occurred 6 months postoperatively. The projected rate of survivorship of UKA was 90.4% at 10 years (95% confidence interval 0.80-1). The projected rate of survivorship with complication at end point was 87.7% at 10 years (95% confidence interval 0.76-0.99)., Conclusion: The present study demonstrated that primary spontaneous osteonecrosis of the knee (SPONK) can be successfully be treated with UKA at a mean follow-up of 6.6 years., Level of Evidence: II.

Purpose: Titanium lunate arthroplasty (TLA) for Kienböck disease was introduced in 1984 to address the silicone-wear particle problem common to silicone lunate implants. We sought to study the outcome of TLA., Methods: We identified 11 patients from our hospital database who had undergone TLA between 2001 and 2010. We evaluated pain, range of motion (ROM), function, and radiological outcome at a mean 11 years after surgery. We compared preoperative ROM and radiological findings with final follow-up in the ipsilateral wrist and also made comparisons with the contralateral wrists., Results: No implants were removed, and no wrist joints were fused. Pain on the visual analog scale averaged 0.5 at rest, 0.3 at night, and 2.7 during heavy exertion. Seven patients had no pain at rest and 9 had no pain at night. Range of motion reached 70% of that of the contralateral wrist, and strength reached 81%. The Disabilities of the Arm, Shoulder, and Hand (DASH) score averaged 9.6, optional DASH 9.7, and Mayo wrist score 67.7. Radiologically, only Ståhl and arthrosis indexes differed significantly between affected and unaffected wrists. Two patients had a dorsally dislocated implant, meaning that around 20% of our cases probably meet the criteria for failure., Conclusions: The longer-term results of TLA for stage III Kienböck disease are promising., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the outcomes of patients with stage III Kienböck disease treated by vascularized bone graft (VBG) followed by temporary scaphocapitate (SC) fixation, a minimum of 2 years after surgery., Methods: Twenty-six patients (mean age, 35 years) with stage III Kienböck disease (16 with stage IIIA and 10 with stage IIIB), treated with VBG followed by SC fixation for 4 months, were retrospectively followed for at least 2 years (range, 24-121 months; mean, 61.8 months). The preoperative and postoperative assessments included range of motion (ROM) of the wrist, grip strength (GS), wrist pain, the modified Mayo wrist score (MMWS), carpal height ratio (CHR), Ståhl index (STI), and radioscaphoid angle (RSA). The outcomes of each assessment of the stages IIIA and IIIB groups at the final examination were compared with those before surgery., Results: In both stages IIIA and IIIB groups, GS increased after surgery. Decrease of CHR and STI was associated with the increase of RSA in the stage IIIA group after surgery, while RSA decreased, although neither CHR nor STI significantly increased in the stage IIIB patients. No patient demonstrated deterioration of the wrist pain after surgery. Twenty-one of 26 patients had an improved MMWS grade at the final follow-up., Conclusions: Vascularized bone graft combined with SC fixation for 4 months provided greater GS, pain relief, and functional improvement compared with before surgery in both stages IIIA and IIIB groups., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The management of Kienböck's disease is complex and constantly evolving in parallel with progress in the understanding of the pathophysiological mechanisms of this condition. Cross-sectional imaging techniques have an essential role in the diagnosis and prognostic assessment of this disease. CT allows the optimal study of the morpho-structure of lunate bone. MRI makes it possible to study bone marrow viability. As for CT arthrography, it allows to evaluate accurately articular cartilage of the different carpal joints. The evaluation of these different aspects of Kienböck's disease is essential for optimal treatment selection. Cross-sectional imaging also has an interest in post-treatment follow-up, by having a prognostic value and allowing the identification of post-operative complications. The purpose of this article is to review the contribution of cross-sectional imaging in the assessment of Kienböck's disease before and after treatment according to the most common surgical procedures. Pathophysiological mechanisms, predisposing factors, the different classifications and their interests will be discussed., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Nonelderly hip fracture patients have gathered little scientific attention, and our understanding of the group may be biased by patient case-mix and lack of follow-up. Preconceptions may thwart adequate investigation of bone health and other comorbidities. This literature review focusses on who these patients between 20 and 60 years are, how to treat them and how to evaluate the outcome. 2-11% of the hip fractures occur in non-elderly, equally common in men and women. Every second to forth patient smoke, have chronic diseases, and abuse alcohol. Poor self-rated health, sleep disturbances, low cognitive function and education are associated with increased hip fracture risk in young adults. Bone health is poorly investigated, but literature suggest young patients to have lower bone mineral density regardless of trauma mechanism. Studies contradict on whether surgery within 8-12 h reduce the risk of avascular necrosis in femoral neck fractures (FNF). Based on rationality, surgery ought to be performed promptly, in order to reduce pain and permit rehabilitation. There is no convincing support from the existing literature to use open reduction. Good reduction is mandatory, preferably using a closed reduction technique. The failure rate following internal fixation of displaced FNF in younger patients can be as high as 59%. In some cases a displaced FNF is better treated with a primary arthroplasty; in case of rheumatoid arthritis or osteoarthritis for example. Complications after extracapsular fractures vary from 6 to 23%. The relatively few studies looking at functional outcome in non-elderly use a multitude of outcome measures, precluding comparisons. Many non-elderly patients seem not to fully recover. While some non-elderly hip fracture patients are healthy individuals sustaining high energy trauma, others have low-energy fractures and comorbidities including reduced bone strength (either as a primary or secondary condition). i.e. non-delaying medical optimization, proper surgical technique, bone health investigation and secondary fracture prevention is necessary. Younger hip fracture patients are at risk of permanent loss of function, and negative socioeconomic and psychological consequences. High-energy trauma does not exclude the presence of osteopenia. A hip fracture in adulthood and middle-age is very seldom caused by bad luck only!, (Copyright © 2018. Published by Elsevier Ltd.)

Blood vessels are essential for the distribution of oxygen, nutrients, and immune cells, as well as the removal of waste products. In addition to this conventional role as a versatile conduit system, the endothelial cells forming the innermost layer of the vessel wall also possess important signaling capabilities and can control growth, patterning, homeostasis, and regeneration of the surrounding organ. In the skeletal system, blood vessels regulate developmental and regenerative bone formation as well as hematopoiesis by providing vascular niches for hematopoietic stem cells. Here we provide an overview of blood vessel architecture, growth and properties in the healthy, aging, and diseased skeletal system., (Copyright © 2018 Cold Spring Harbor Laboratory Press; all rights reserved.)

Kienböck disease is uncommon in skeletally immature patients. Although there is no gold standard treatment for Kienböck disease in the skeletally immature patient, surgical and nonsurgical treatment options have been shown to be effective. Initial immobilization with a cast, protection with an orthosis, and avoidance of repetitive forceful activities have been shown to be effective in some cases. Surgery may be offered to the skeletally immature patient when nonsurgical treatment is ineffective. Among several surgical techniques used for treatment in the skeletally immature patient with Kienböck disease, distal radial osteotomies have been the most frequently performed surgery; however, radial overgrowth is a concern. There is a great potential for revascularization and remodeling of the lunate in the skeletally immature patients with Kienböck disease. Good and excellent clinical and radiological outcomes can be achieved with both nonsurgical and surgical treatments., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to report our results of lunate excision combined with capitohamate fusion in the treatment of Kienböck's stage IIIB/IIIC disease., Methods: A total of 7 patients with a mean age 35.2 (SD 11.5) years were enrolled in the study. Pain was the principal reason for surgery. All operations were carried out by the same senior surgeon. Patients were evaluated in terms of range of motion, DASH and VAS scores, satisfaction, and grip/tip/palmar/key pinch strength compared with contralateral sides. Preoperative carpal height indexes and findings of osteoarthritis were determined radiographically and compared with postoperative evaluations., Results: Mean duration of follow up was 15.2 months. Mean DASH and VAS scores were 13.8 2.7 and 2 1.1 respectively. The mean patient satisfaction score was 3.2 0.4 over 4 points. The mean grip strength in the operated hands was 66.4%, palmar pinch was 75.1%, tip pinch was 71.8% and key pinch was 70.4% when compared to the contralateral unaffected sides. The mean flexion range in the operated hands was 58.8%, extension range was 60.3%, radial deviation range was 65.2% and ulnar deviation range was 65.7% when compared to the contralateral sides. There was no significant difference between preoperative and postoperative carpal height ratios (p = 0.086)., Conclusions: Our early term results indicate that lunate excision combined with capitohamate fusion may be an alternative treatment option in patients with stage IIIB and IIIC Kienböck's disease., Level of Evidence: Level IV, Therapeutic study., (Copyright © 2018 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Background: During the direct anterior approach for total hip arthroplasty, a retractor is placed on the anterior wall of the acetabulum to retract the iliopsoas muscle. This step with the retractor has been reported to put the patient at risk for femoral nerve damage. The present study aimed to clarify the effects of the anterior acetabular retractor on the status of the femoral nerve during the direct anterior approach on the basis of transcranial motor-evoked potential (MEP) analysis., Methods: Between July 2016 and February 2017, 22 patients underwent primary total hip arthroplasty via the direct anterior approach with MEP analysis. The integrity of the femoral nerve was tested at 3 time points: preoperatively, as a control (first period); just after retractor placement on the anterior wall of the acetabulum (second period); and after the procedure (third period). The association between operative time and femoral nerve status was examined. Postoperative femoral nerve damage was determined by the presence of causalgia and the results of a manual muscle test (MMT) for strength of knee extension., Results: The mean amplitude of the femoral nerve was significantly reduced, from 100% in the first period to 54% (range, 5% to 100%) in the second period (p < 0.01), but then significantly improved to 77% (range, 20% to 100%) in the third period (p < 0.01). In 17 (77%) of the 22 patients, the amplitude of the femoral nerve in the second period was reduced, while only 5 patients (23%) showed no reduction. The mean operative time was 83 minutes (range, 63 to 104 minutes), and no significant correlation was observed between operative time and improvement of femoral nerve status between the second and third periods (p = 0.83 and r = -0.05). All 22 patients had a postoperative MMT grade of 5 for knee extension without causalgia of the femoral nerve., Conclusions: On the basis of the MEP analysis, 17 (77%) of the 22 patients showed a significant reduction of the femoral nerve amplitude despite careful placement of the retractor on the anterior wall of the acetabulum. Although this reduction appears reversible, placement of an anterior retractor should be performed with careful attention to the femoral nerve., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Traumatic inferior shoulder dislocation (ISD) is rare, estimated to occur in 0.5% of all shoulder dislocations. We describe the demographics, natural history and outcome of this injury., Hypothesis/aim: The aim of the study is to provide a summary of the demographics, clinical presentation, management and outcome of patients who suffer ISD METHODS: We conducted a systematic review of the English language literature on ISD using PubMed, Medline, CINHAL, Cochrane Database and Evidence-Based Medicine Reviews. Articles were examined independently by two of the authors and data were extracted using a standard form. Descriptive statistics were performed., Results: 199 patients were identified, from 101 articles. Mean age was 44 years (range 13-94 years). All cases were caused by trauma, with falls accounting for 44% of all cases. There were three reported cases (2%) of open dislocations and 29 cases (15%) of bilateral ISD. Proximal humerus and scapular fractures were reported in 39 and 8% of patients, respectively. Neurological injury after dislocation was noted in 58 patients (29%). Vascular injury was noted in 20 patients (10%), which included axillary arterial injury in 19 patients and an upper limb deep vein thrombosis in one patient. Follow-up data were available for 107 patients (54%), with an average duration of 2.7 years (1 week-32 years). Avascular necrosis (AVN) was noted between 8 weeks and 2 years after initial injury in three patients (1.5%)., Conclusion: Clinical and radiographic assessment of ISD is key to diagnosis and successful reduction. Patients can be treated with shoulder immobilisation for 2-3 weeks. In the setting of ongoing pain or instability, further imaging should be performed. The outcome of ISD is generally favourable.

Steroid-associated osteonecrosis (SAON) often requires surgical core decompression (CD) in the early stage for removal of necrotic bone to facilitate repair where bone grafts are needed for filling bone defect and avoiding subsequent joint collapse. In this study, we developed a bioactive composite scaffold incorporated with icariin, a unique phytomolecule that can provide structural and mechanical support and facilitate bone regeneration to fill into bone defects after surgical CD in established SAON rabbit model. An innovative low-temperature 3D printing technology was used to fabricate the poly (lactic-co-glycolic acid)/β-calcium phosphate/icariin (PLGA/TCP/Icariin, PTI) scaffold. The cytocompatibility of the PTI scaffold was tested in vitro, and the osteogenesis properties of PTI scaffolds were assessed in vivo in the SAON rabbit models. Our results showed that the fabricated PTI scaffold had a well-designed biomimic structure that was precisely printed to provide increased mechanical support and stable icariin release from the scaffold for bone regeneration. Furthermore, our in vivo study indicated that the PTI scaffold could enhanced the mechanical properties of new bone tissues and improved angiogenesis within the implanted region in SAON rabbit model than those of PLGA/TCP (PT) scaffold. The underlying osteoblastic mechanism was investigated using MC3T3-E1 cells in vitro and revealed that icariin could facilitate MC3T3-E1 cells ingrowth into the PTI scaffold and regulate osteoblastic differentiation. The PTI scaffold exhibited superior biodegradability, biocompatibility, and osteogenic capability compared with those of PT scaffold. In summary, the PTI composite scaffold which incorporated bioactive phyto-compounds is a promising potential strategy for bone tissue engineering and regeneration in patients with challenging SAON., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

This study aimed to evaluate femoral perfusion using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for two weeks after the simultaneous initiation of electrical stimulation (ES) and steroid treatment in a steroid-induced osteonecrosis (ON) model. A single dose of methylprednisolone was injected into 14 rabbits. Seven rabbits underwent ES (ES group), and seven rabbits did not (control group). DCE-MRI was performed before steroid administration and 1, 5, 10, and 14 days after steroid administration. Regions of interest were set in the bilateral proximal femora. The enhancement ratio, initial slope, and area under the curve were analyzed. These parameters were evaluated after steroid administration in each group and between the two groups, and the ratios of ON in both groups were compared. In the control group, the minimum values of all parameters decreased significantly after steroid administration (P < 0.05), but in the ES group, the parameters did not decrease. In the ES group, all parameter values were significantly increased on the 10th and 14th days (P < 0.05). All parameter values in the ES group were significantly higher than those in the control group on the 14th day (P < 0.05). In the control group, ON was detected in three of five rabbits (in three of ten femora). In the ES group, ON was not detected. These results suggest that increased femoral blood flow elicited by ES may be related to ON prevention after steroid administration.

Objective: Kienböck's disease is a commonly seen posttraumatic avascular necrosis characterized by avascular necrosis of the lunate bone of the wrist which involves the dominant hand. In our study, we aimed to present midterm outcomes of 12 cases treated with radial metaphyseal core decompression., Patients and Methods: In our clinic, 12 patients who applied to our outpatient clinic with intractable pain despite at least six weeks of conservative treatment were previously diagnosed and evaluated as Kienböck's disease between the years 2006 and 2014. Patients at early stage received radial metaphyseal core decompression., Results: The patients were evaluated as postoperative grip strength, flexion-extension gap, ulnar-radial deviation gap, VAS, Quick DASH and MAYO wrist scoring and patient satisfaction., Conclusions: We determined that interventions performed for Kienböck's disease cannot halt radiological progression. We are of the opinion that radial metaphyseal core decompression, aiming at increasing blood perfusion, improve early diagnosis and treatment of Kienböck's disease, increasing the patient satisfaction.

Background: Radius osteotomy is one of the standard surgical procedures for the treatment of Kienböck's disease. Unfortunately, radius osteotomy can result in an incongruous distal radio-ulnar joint (DRUj) postoperatively, because the procedure is performed proximal to the DRUj., Methods: A very distal radius wedge osteotomy was performed as a 15-degree lateral closing wedge osteotomy with the apex of the wedge distal to that of conventional lateral closing wedge osteotomy; this procedure was developed to avoid postoperative incongruous DRUj. We performed this procedure on 6 patients (stage III-A: 1, stage III-B: 5) with a mean age of 49 years. Clinical and radiographic evaluations were performed at a mean follow-up of 32 months., Results: Wrist pain disappeared in all patients. Mean grip strength improved from 35% to 87% of the contralateral side (p = 0.0255). Mean range of motion, measured as flexion-extension arc, improved from 93 to 128 degrees. Nakamura's score was good in all patient. Mean lunate covering ratio increased from 61% to 90% (p = 0.0151) and mean sigmoid notch inclination angle, a radiographic parameter of DRUj congruency, was not significantly different between pre-operative and final follow-up evaluation. No clinical or radiographic DRUj osteoarthritis findings were observed., Conclusions: Our procedure of very distal radius wedge osteotomy provided satisfactory clinical results without an incongruous DRUj. This technique might prevent the occurrence of postoperative DRUj osteoarthritis.

This is a retrospective case-control study.The aim of this study was to compare the surgical results of percutaneous kyphoplasty (KP) and posterior spinal fixation with vertebroplasty (PSF+VP) for treatment of Kümmell disease (KD).KD is rare form of post-traumatic delayed avascular necrosis of the vertebral body. It is reported that KP is an effect measure for treatment of KD. Some studies have recommended posterior spinal fixation with vertebroplasty for KD.A total of 100 patients with KD who underwent spinal surgery at our hospital were enrolled from January 2008 to December 2013. The inclusion criteria were monosegment lesion without neurological deficit; the segments are restricted to T11-L2; conservative treatment is invalid. The exclusion criteria were metastatic spinal tumors, infection, primary bone tumor, and multiple myeloma; bisegments and multi-segments; patients with neurological symptoms; the defect of posterior wall of vertebral body; the occupying of vertebral canal. The symptomatic vertebrae were restricted to T11-L2. Patients who were followed-up for less than 2 years after surgery were excluded. Finally, there are 25 patients in the KP group and 21 in the PSF+VP group. There were no significant differences in patient age, disease duration, or the length of follow-up between the 2 groups.Operative time (43.2 ± 21.8 vs 230.6 ± 87.1 minutes) was significantly longer and bleeding volume (5.3 ± 3.1 vs 215.0 ± 170.2 mL) significantly greater in the PSF+VP group. No significant difference between the 2 groups was observed in Visual analog scale score (VAS) (1.3 ± 0.9 vs 1.2 ± 0.9), Oswestry disability index score (ODI) (27.2 ± 9.0 vs 26.0 ± 6.3), and Cobb angle (17.0 ± 7.2 vs 16.5 ± 2.8). KP resulted in a shorter operation time, less bleeding volume, and fewer postoperative complications than PSF+VP.This study shows that both treatments KP and PSF+VP for KD can be safe and effective for the patients with monosegment lesion and without neurological deficit. However, KP show the advantages in a shorter surgical duration, less blood loss, and fewer postoperative complications., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)