Apoptosis in the Osteonecrosis of the Femoral Head

Yoon-Seok Youm,Soo-Youn Lee,Soo-Ho Lee 대한정형외과학회 2010 Clinics in Orthopedic Surgery Vol.2 No.4

Background: Osteonecrosis of the femoral head is classified into idiopathic and secondary forms. A number of etiological factors in the development of osteonecrosis have been suggested but the biological mechanisms are still unclear. Recently, some reports suggested that the apoptosis is closely related to osteonecrosis of the femoral head. Therefore, this study examined the expression of apoptosis in osteonecrosis of the femoral head. Methods: Of the patients diagnosed preoperatively with osteonecrosis and underwent total hip replacement arthroplasty between August 2004 and July 2005, 58 patients (58 hips) were available for this study. Their diagnoses were confirmed by the postoperative pathology findings. Tissue samples of the femoral head sections were terminal deoxynucleotydyl transferase mediated dUTP nick-end labeling (TUNEL) stained using an in situ cell death detection POD kit. The number of total and TUNEL-positive osteocytes, and the average ratio of TUNEL-positive cells were calculated and analyzed according to the cause. Results: Osteonecrosis was steroid-induced in 8 cases (13.8%), alcohol-induced in 29 cases (50%), post-traumatic in 6 cases (10.3%) and idiopathic in 15 cases (25.9%). The percentage of TUNEL-positive osteocytes was high in patients with steroid- and alcohol-induced osteonecrosis of the femoral head but low in patients with post-traumatic and idiopathic osteonecrosis. The difference in the percentage of TUNEL-positive osteocytes between these groups was significant (p < 0.05). Conclusions: Apoptosis might play an important role in the pathogenesis of osteonecrosis of the femoral head induced by steroid and alcohol. These findings highlight a need for further research into the role of apoptosis in the development of osteonecrosis of the femoral head.

A Comparison of Surgical Methods of Inducing Femoral Head Osteonecrosis in Rats

김준수,박진욱,최석화,김근형 한국임상수의학회 2010 한국임상수의학회지 Vol.27 No.3

Osteonecrosis of the femoral head is an idiopathic and progressive disease. It was reported that several animal models have been used for the research of osteonecrosis. However, no standardized animal model for the study of osteonecrosis has been developed to date. This study was conducted to compare the degree of osteonecrosis of three surgically induced osteonecrosis models in rats. Twenty Sprague-Dawley rats (24 weeks old, male) were divided into three experimental groups and a control group, five heads each. Three groups were surgically induced into osteonecrosis; the ligamentum teres were cut and the periosteum of the femoral neck was stripped (Group S), the steel wire was ligated to the neck of the femoral head (Group W), and the femoral neck was tied up with a wire in the same way as in the W group, and burned by attaching the electrode tip to the wire and then the wire was removed (Group B). After two weeks, rats were sacrificed and the femoral head and neck were collected. Histological findings were evaluated with H/E stains, Safranin-O and TUNEL for osteonecrotic lesions in the bones and cartilages of the femoral head. Osteonecrosis was induced successfully in all groups (Group S, W and B) in two weeks, a short period of time. Significant necrotic changes of the cartilage were detected only in Group B. In the modified cautery model in particular, the method of removing the wire after cautery was completed in the experimental model of osteonecrosis more efficiently than any other method.

Traumatic and Non-traumatic Osteonecrosis in the Femoral Head of a Rabbit Model

Yawon Hwang,Jinuk Park,Seok Hwa Choi,Gonhyung Kim 한국실험동물학회 2011 Laboratory Animal Research Vol.27 No.2

Osteonecrosis of the femoral head is an idiopathic, debilitating and progressive disease. A number of traumatic or non-traumatic animal models have been reported for research on osteonecrosis. This study was performed to compare the efficacy of femoral head osteonecrosis in rabbits by traumatic and nontraumatic methods. Twenty-seven New Zealand White rabbits were divided into three experimental groups, nine heads each. Two groups were surgically induced into osteonecrosis; a steel cerclage wire was ligated tightly around the neck of the right femoral head (Group W), and the femoral neck was tied with a cerclage wire in the same way as in the W group, and burned by attachment of an electrode tip to the wire and then the wire was removed (Group B). The other group was induced into osteonecrosis with a single intra-muscular injection of 20 ㎎/㎏ methyl-prednisolone acetate single injection (Group M). In the control group, the left femoral head of animals in group W and B was used. After two weeks, rabbits were sacrificed and the femoral head and neck were collected. Osteonecrosis of the femoral head was evaluated by radiography, histology and immunohistology methods. Osteonecrosis lesions in the femoral head were identified in traumatic models of groups W and B. Cartilage degeneration in the superficial layer and TUNEL positive cells in the femoral head were detected more in Group B than in Group W. These findings revealed that short-term induced osteonecrosis of the femoral head was effectively achieved by cautery around the femoral neck.

민간직업 잠수부의 골괴사에 대한 역학적 조사 및 혈청 표지자 분석

이주엽 ( Ju Yup Lee ),송주현 ( Joo Hyoun Song ),이한용 ( Han Yong Lee ),고해석 ( Hae Seok Koh ),정진영 ( Jin Young Jeong ),유기원 ( Kee Won Rhuy ),강용구 ( Yong Koo Kang ),김승준 ( Seung Jun Kim ) 대한고관절학회 2006 Hip and Pelvis Vol.18 No.3

목적: 민간 직업 잠수부의 골괴사에 대한 역학 조사를 통해 골괴사 발생의 위험 인자를 알아보고, 골괴사와 관련이 있다고 알려진 혈청 표지자 분석을 통하여 이들에서 발생하는 골괴사와 혈전 기호증 및 저섬유소 용해증 사이의 상관 관계를 알아보고자 하였다. 대상 및 방법: 키조개를 채취하는 직업 잠수부중 골괴사가 발생한 10명(제1군)과 발생하지 않은 32명(제2군), 총 42명을 대상으로 잠수경력, 연간 잠수횟수, 하루 평균 잠수횟수, 평균 잠수 시간 및 깊이, 잠수 방식 등을 조사하여 두 군 사이에서 상기 항목들의 통계학적 유의성을 알아보았다. 또한 연구대상 잠수부 전체에서 고지혈증 표지자, 혈전 기호증 표지자, 저섬유소 용해 표지자 그리고 homocystein 등을 측정하고, 20명의 의사로 이루어진 대조군(제3군)과 비교하여, 이압성 골괴사와 혈청 표지자 사이의 연관성 여부를 알아보았다. 결과: 제1군과 2군 사이에서 통계학적으로 유의성을 보였던 항목은 평균 잠수 시간으로 1군은 평균 124분, 2군은 62.1분 이었으며(P<0.05), 나머지 항목들은 통계학적 유의성이 없었다. 혈청 표지자 분석에서는 1군과 2군 사이에서는 모든 표지자가 통계학적 유의성을 보이지 않았으나, 3군과 1, 2군 사이의 비교에서는 1, 2군에서 protein C와 S의 활성도가 유의하게 감소되어 있었고(Protein C : P<0.05, Protein S : P<0.05), plasminogen activator inhibitor-1(PAI-1)의 유의한 증가가 관찰되었다(P<0.05). 결론: 민간 직업 잠수부에 대한 조사 결과, 골괴사가 발생한 잠수부들의 평균 잠수 시간이 두 배 이상으로 길었으며, 대조군과의 혈청 표지자 분석에서는 잠수부들에서 protein C와 S의 활성도가 감소되어 있었고, PAI-1의 증가가 관찰되었다. Purpose: To evaluate the risk factors for the development of osteonecrosis in civilian professional divers by an epidemiologic study and to determine the correlation between osteonecrosis in divers and coagulopathy by analysis of serologic markers that are related to thrombophilia and hypofibrinolysis. Materials and Methods: Forty-two divers, who collected pen shells (Atrina pinnata), and among whom 10 had osteonecrosis (group 1), were compared with 32 divers without osteonecrosis (group 2). Both groups were evaluated based on the number of years of diving experience, number of dives per year, mean number of dives per day, mean diving time and depth, and diving methods. We determined any statistically significant differences among these variables. We measured the levels of serologic markers that were related to hyperlipidemia, thrombophilia, and hypofibrinolysis from the divers and a control group of 20 physicians (group 3). The levels of the serologic markers were compared between groups 1 and 2 and between the divers and the control group, in order to determine the relationship between the serologic markers and the development of dysbaric osteonecrosis. Results: None of the variables demonstrated any statistically significant differences, except for the mean diving time, in which group 1 had a mean diving time of 124 minutes and group 2 had a mean diving time of 62.1 minutes (P<0.05). In the analysis of the serologic markers, there were no statistically significant differences between groups 1 and 2; however, in comparison with the group 3, the divers demonstrated significantly decreased activity levels of proteins C and S (Protein C: P<0.05; Protein S: P<0.05), and an increase in the levels of plasminogen activator inhibitor-1 (PAI-1) (P<0.05). Conclusion: The divers with osteonecrosis had a longer mean diving time than did those divers without osteonecrosis. In the serologic marker analysis, the divers with osteonecrosis demonstrated significantly decreased activity levels of Proteins C, S and a significant increase in the levels of PAI-1, compared with the control group.

Hip&Pelvis : CASE REPORT : Osteonecrosis of the Femoral Head in the Setting of a Complex Acetabulum Fracture without Hip Dislocation Treated Surgically Using Ilio-inguinal Approach: A Case Report

( Anshul Shyam Sobti ),( Kwang Jun Oh ) 대한고관절학회 2014 Hip and Pelvis Vol.26 No.3

Osteonecrosis in isolated fractures of the acetabulum without dislocation of hip seems to be a known complication, but to our knowledge it has not been reported adequately. The causative nature of post-traumatic femoral head osteonecrosis has not been studied critically. The pathophysiology of osteonecrosis in this case also eludes us. Striking evidence points towards the intra-operative blood loss and low mean arterial pressure possibly leading to hypo-perfusion of femoral head leading to osteonecrosis. Fractures of the acetabulum pose a difficult problem for the patient and the surgeon because of possible complications. Thus any surgeon involved in surgery for fractures of the acetabulum should be aware of the possibility of this potential complication. Here is a 61-year male, who sustained a complex fracture of the acetabulum without hip dislocation, subsequently was treated surgically with internal fixation using an anterior approach, 10 months after surgery patient developed osteonecrosis of the femoral head.

다발성 무혈성괴사

김종원 ( Jong Won Kim ),유정준 ( Jeong Joon Yoo ),김희중 ( Hee Joong Kim ) 대한고관절학회 2008 Hip and Pelvis Vol.20 No.4

목적: 다발성 무혈성 골괴사 환자들의 임상적 양상을 알아보고자 하였다. 대상 및 방법: 고관절과 더불어 다른 관절에 이환된 경우를 다발성 무혈성 골괴사로 정의하고, 1982년 1월부터 2003년 12월까지 본원 정형외과에서 확인된 다발성 무혈성 골괴사 환자의 위험인자, 이환 부위, 증상 등 임상 양상을 분석하였다. 결과: 고관절 무혈성 골괴사 1740환자 중 33명(2%)에서 다발성 무혈성괴사가 확인되었다. 남자 16예, 여자 17예였으며, 평균 연령은 48.7세(28~74)였다. 원인적 위험인자로 전신성 홍반성 낭창(6예), 재생불량성 빈혈(2예), 악성종양(2예), 다발성 경화증(1예), 특발성 간질 폐섬유증(1예), 감압병(1예), 특발성(9예), 과도한 음주(6예) 등이 있었고, 33명중 17명(52%)에서 스테로이드 복용 병력이 있었다. 부위는 대퇴 골두 부위 33예, 대퇴 및 경골과 부위 22예, 상완 골두 부위 13예, 거골체 부위 4예, 주상골 부위 양측 1예였다. 전체 132부위로 환자당 4.0부위를 침범하였다. 결론: 스테로이드를 사용한 경우 다발성 무혈성 골괴사의 빈도가 높았다. 따라서 임상적 증상이 있는 경우에는 골주사 등을 포함한 정밀 검사가 필요할 것으로 사료된다. Purpose: We wanted to evaluate the clinical characteristics of patients with multifocal osteonecrosis. Materials and Methods: When two or more anatomic sites were affected by osteonecrosis, this was defined as multifocal osteonecrosis. We retrospectively reviewed the cases of multiple osteonecrosis that were diagnosed between January 1982 and December 2003, and we analyzed such clinical characteristics as the risk factors, the involved sites and the symptoms. Results: Thirty-three of 1740 patients (2%) with multifocal osteonecrosis were found. They were 16 men and 17 women with a mean age of 48.7 years (range: 28 to 74). The associated factors included systemic lupus erythematosus (6 patients), aplastic anemia (2 patients), malignancy (2 patients), multiple sclerosis (2 patients), idiopathic pulmonary fibrosis (1 patient), Caisson`s disease (1 patient), idiopathic (9 patients) and alcohol abuse (6 patients). Seventeen of 33 patients (52%) had a history of corticosteroid therapy. The involved sites included 33 femoral heads, 22 femoral and tibial condyles, 13 humeral heads, 4 talar bodies and 1 scaphoid. In total, 132 sites were involved (4.0 per patients). Conclusion: Chronic steroid therapy affected the high incidence of multifocal osteonecrosis. Therefore, further studies that would include bone scans are needed for patients who undergo steroid therapy, and especially when these patients show clinical symptoms.

A Novel Model of Osteonecrosis in the Knee Joint

( Seung Hwan Hong ),( Hyun Shin Park ),( Cheong Ho Chang ),( In Tak Chu ),( Sae Bom Lee ),( Ju Hee Park ),( Jang Hun Kim ),( Seon Ae Kim ),( Sang Hoon Woo ),( Sun Sin Choi ),( Seok Jung Kim ) 한국조직공학·재생의학회 2010 조직공학과 재생의학 Vol.7 No.1

As the necrotic portions of the epiphysis in the current animal models are focal and the extent of necrosis also varies, these models are not suitable for treatment evaluation such as cell therapy. We will describe a new osteonecrosis model which shows total and constant necrosis of the epiphysis and can be for human treatment evaluation. Fifteen New Zealand white rabbits were used for making the osteonecrosis model. Their right knees were incised longitudinally using an anteromedial approach, and the femoral condyles were exposed. After dissecting the ligaments surrounding the distal femur, the metaphyseal-diaphyseal junction was cut using a saw, and the whole femoral condyle was isolated. After three liquid nitrogen treatments, the isolated femoral condyle was internally fixated to the femoral shaft using two or three k-wires. Radiographs were taken at four, 12, and 24 weeks postoperatively, and five rabbits were sacrificed at each time point. The necrotic regions with portions of the osteotomy areas were extracted, and the tissue sections were stained with hematoxylin-eosin and Masson`s trichrome. The tissue reactions showed sluggish reparative processes in which granulation and fibrous tissue sluggishly penetrated necrotic tissue from the osteotomy sites. Viable osteocytes with well-stained nuclei were not present in necrotic areas at any stage. The distal femoral condyle of the rabbit is an appropriate model for demonstrating osteonecrosis. It is hoped that this model will facilitate future assessments of new, human treatment modalities.

Arthroplasty in Femoral Head Osteonecrosis

( Yoon Je Cho ),( Dong Cheol Nam ),( Kwang Young Jung ) 대한고관절학회 2014 Hip and Pelvis Vol.26 No.2

Osteonecrosis of the femoral head is a destructive joint disease requiring early hip arthroplasty. The polyethylene-metal design using a 22-mm femoral head component, introduced by Charnley in 1950, has been widely used for over half a century. Since then, different materials with the capacity to minimize friction between bearing surfaces and various cement or cementless insert fixations have been developed. Although the outcome of second and third generation designs using better bearing materials and technologies has been favorable, less favorable results are seen with total hip arthroplasty in young patients with osteonecrosis. Selection of appropriate materials for hip arthroplasty is important for any potential revisions that might become inevitable due to the limited durability of a prosthetic hip joint. Alternative hip arthroplasties, which include hemiresurfacing arthroplasty and bipolar hemiarthroplasty, have not been found to have acceptable outcomes. Metal-on-metal resurfacing has recently been suggested as a feasible option for young patients with extra physical demands; however, concerns about complications such as hypersensitivity reaction or pseudotumor formation on metal bearings have emerged. To ensure successful long-term outcomes in hip arthroplasty, factors such as insert stabilization and surfaces with less friction are essential. Understanding these aspects in arthroplasty is important to selection of proper materials and to making appropriate decisions for patients with osteonecrosis of the femoral head.

Electron microscopic analysis of necrotic bone and failed implant surface in a patient with medication-related osteonecrosis of the jaw

Ji Young Ha,Mi Young Eo,Buyanbileg Sodnom-Ish,Kezia Rachellea Mustakim,Hoon Myoung,Soung Min Kim 대한악안면성형재건외과학회 2023 Maxillofacial Plastic Reconstructive Surgery Vol.45 No.-

Background Bisphosphonates (BP), a commonly used medication for various bone diseases, have been known to have severe complications such as bisphosphonate-related osteonecrosis of the jaw (BRONJ). Failure of dental implants has also been found in patients with medication-related osteonecrosis of the jaw (MRONJ). In this study, we analyzed the necrotic bone tissues and the surface of the failed implants removed from the jaw in patients treated with BPs and antiresorptive agents. Results Chronic inflammatory cells with collagen and fibrous tissues and bone sequestrum were shown at 5.0 × , 10.0 × , 20.0 × , and 40.0 × magnified histologic sections in the bone and fibrotic scar tissues removed from patients with MRONJ due to osteonecrosis. Hardened bone tissues with microcracked bony resorbed lacunae were observed in SEM. Unlike the previously published comparative data where immune cells, such as dendritic cells, were found in the failed implant surface, these immune cells were not identified in the BRONJ-related peri-implantitis tissues through the TEM investigations. Furthermore, EDS revealed that in addition to the main titanium element, gold, carbon, oxygen, calcium, phosphorus, silicon, and sulfur elements were found. Conclusion Hardened bone tissues with microcracked bony resorbed lacunae were observed in the SEM findings, which were considered as the main characteristic of the osteonecrosis of the jaw. Immune cells, such as dendritic cells were not identified in the TEM. EDS showed that in addition to the main titanium element, gold, carbon, oxygen, calcium, phosphorus, and silicon elements were found. Furthermore, it was revealed that sulfur was found, which was considered to be one of the complicated causes of implant failure in patients with BRONJ.

고령의 환자에서 발생한 스테로이드 유발성 골괴사증 : 1예 보고 A Case Report

조진호,오형근 白中央醫療院 2004 仁濟醫學 Vol.25 No.1

Steroid induced osteonecrosis of the knee is a relatively uncommon disease and occurs primarily in patients younger than 50 years of age with immunocompromising disorders. Compared with spontaneous osteonecrosis, steroid induced osteonecrosis produces a more diffuse pattern of bone necrosis and frequently occurs in bilaterally. Although other treatment modalities have been reported, total knee arthroplasty can be considered as a successful procedure for steroid induced osteonecrosis. We encountered the case of 69 year old female who was diagnosed as bilateral steroid induced osteonecrosis of the knee without underlying immunocompromised disorders.