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Fulltext Comment on: Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management

Ngeow WC, Chai WL

Singapore Med J, 2019 01;60(1):52.
PMID: 30840997 DOI: 10.11622/smedj.2019006
Matched MeSH terms: Osteonecrosis*
Core decompression combined with local DFO administration loaded on polylactic glycolic acid scaffolds for the treatment of osteonecrosis of the femoral head: a pilot study

Gharanizadeh K, Sharifi AM, Tayyebi H, Heidari R, Amiri S, Noorigaravand S

BMC Pharmacol Toxicol, 2023 Sep 05;24(1):44.
PMID: 37670365 DOI: 10.1186/s40360-023-00682-x

BACKGROUND: Deferoxamine (DFO) angiogenesis induction potential has been demonstrated in earlier studies, but not in the osteonecrosis of the femoral head (ONFH). In this study, we evaluated the outcome of ONFH treated with combined core decompression and local DFO administration loaded on Polylactic Glycolic Acid (PLGA).
PATIENTS AND METHODS: In a pilot experimental study, six patients (10 hips) with early-stage non-traumatic ONFH were treated by core decompression, and concurrent injection of local DFO loaded on PLGA scaffold into the subchondral femoral head. Outcome measures were evaluated before the surgery and 12 and 24 months after the surgery and included visual analog scale (VAS) for pain, modified Merle d'Aubigné-Postel (MAP) score for hip function by MRI, and rate of osteonecrosis assessed by the modified.
RESULTS: The mean MPA score was 14.7 ± 1.16 before the surgery and 16.7 ± 1.41 one year after the surgery (P = 0.004). The mean VAS for pain was 4.7 ± 1.25 before the surgery and 1.8 ± 1.03 one year after the surgery (P = 0.005). The mean Kerboul angle was 219 ± 58.64 before the operation and 164.6 ± 41.82 one year after the operation (P

Matched MeSH terms: Osteonecrosis*
Fulltext Open total talus dislocation: a case report

Tan E, Chua H, Ooi C, Zulkiflee O

Malays Orthop J, 2012 Nov;6(3):60-2.
PMID: 25279062 MyJurnal DOI: 10.5704/MOJ.1207.009

Total talus dislocation is a rare injury and is commonly accompanied by associated fractures. Common worrisome sequelae are infection, avascular necrosis and post-traumatic arthritis. We report here on a patient who sustained an open total talus dislocation with an ipsilateral medial malleolus fracture. Following early debridement, reduction and a combination of internal and external fixations, early recovery was good with no evidence of avascular necrosis.

Matched MeSH terms: Osteonecrosis
Fulltext Modular endoprosthetic replacement after total femur resection for malignant bone tumor

Faisham WI, Zulmi W, Halim AS

Med J Malaysia, 2005 Jul;60 Suppl C:45-8.
PMID: 16381283

Total femur endoprothesis is an alternative replacement for massive malignant bone tumor with intramedullary extension or skip lesion. Four patients underwent total femoral resection and replacement with megaprosthesis: three had primary malignant bone tumor and one had salvage procedure for aseptic loosening of the distal femoral replacement. Tumor-free margins were achieved in all patients with two patients required vascularized latissimus dorsi free flap cover for reconstruction of soft tissue defects. The average follow-up was 24 months (range 16 - 60 months). All four patients were still alive with three of them being disease-free and one survived even with the presence of lung metastasis. The functional results obtained were either excellent or good in all patients in accordance to the Musculoskeletal Tumors Society grading system.

Matched MeSH terms: Osteonecrosis/surgery*
Thermomechanical damage in cortical bone caused by margins of surgical drill bit: A finite element analysis

Akhbar MFA

Comput Methods Programs Biomed, 2023 Apr;231:107361.
PMID: 36736133 DOI: 10.1016/j.cmpb.2023.107361

BACKGROUND AND OBJECTIVE: Conventional surgical drill bits suffer from several drawbacks, including extreme heat generation, breakage, jam, and undesired breakthrough. Understanding the impacts of drill margin on bone damage can provide insights that lay the foundation for improvement in the existing surgical drill bit. However, research on drill margins in bone drilling is lacking. This work assesses the influences of margin height and width on thermomechanical damage in bone drilling.
METHODS: Thermomechanical damage-maximum bone temperature, osteonecrosis diameter, osteonecrosis depth, maximum thrust force, and torque-were calculated using the finite element method under various margin heights (0.05-0.25 mm) and widths (0.02-0.26 mm). The simulation results were validated with experimental tests and previous research data.
RESULTS: The effect of margin height in increasing the maximum bone temperature, osteonecrosis diameter, and depth were at least 19.1%, 41.9%, and 59.6%, respectively. The thrust force and torque are highly sensitive to margin height. A higher margin height (0.21-0.25 mm) reduced the thrust force by 54.0% but increased drilling torque by 142.2%. The bone temperature, osteonecrosis diameter, and depth were 16.5%, 56.5%, and 81.4% lower, respectively, with increasing margin width. The minimum thrust force (11.1 N) and torque (41.9 Nmm) were produced with the highest margin width (0.26 mm). The margin height of 0.05-0.13 mm and a margin width of 0.22-0.26 produced the highest sum of weightage.
CONCLUSIONS: A surgical drill bit with a margin height of 0.05-0.13 mm and a margin width of 0.22-0.26 mm can produce minimum thermomechanical damage in cortical bone drilling. The insights regarding the suitable ranges for margin height and width from this study could be adopted in future research devoted to optimizing the margin of the existing surgical drill bit.

Matched MeSH terms: Osteonecrosis*
Fulltext Cannulated screw fixation for femoral neck fractures: a 5-year experience in a single institution

Khoo, C. C. H., Amber Haseeb, Vivek Ajit Singh

Malays Orthop J, 2014;8(2):14-21.
MyJurnal

Cannulated screw fixation is a widely accepted surgical method for management of fractures of the neck of femur especially in patients with poor premorbid conditions, minimally displaced fractures and those from a younger age group. A five year retrospective study was carried out in 53 consecutive patients between 2006 to 2010 to determine the pattern of injuries, management, outcomes and the associated predictive factors.All the patients underwent cannulated screw fixation, with 37 (69.8%) having had surgery within 24 hours and the remaining 16 (30.2%) 24 hours after the initial injury. All patients were followed up to union of fractures and complications thereafter if any. Good outcome was observed in 43 (81.1%) patients leaving only 10 (18.9%) patients with a poor outcome, of whom nine developed avascular necrosis (90%) and one non-union (10%). We found no significant relationship between the incidence of avascular necrosis and age of patient, fracture displacement, numbers of cannulated screws used, fracture reduction acceptability and anatomical location of the fracture. The time interval from injury to surgery and the presence of posterior comminution did seem to influence the rate of avascular necrosis but due to the small number of patients, was not statistically significant.We conclude that cannulated screw fixation is a viable option of treatment for fractures of the neck of femur.

Matched MeSH terms: Osteonecrosis
A case of dengue-related osteonecrosis of the maxillary dentoalveolar bone

Al-Namnam NM, Nambiar P, Shanmuhasuntharam P, Harris M

Aust Dent J, 2017 Jun;62(2):228-232.
PMID: 27743399 DOI: 10.1111/adj.12472

Dengue is a mosquito transmitted flaviviral infection which can give rise to severe haemorrhage (dengue haemorrhagic fever) and with capillary leakage induces hypovolaemic shock (dengue shock syndrome). Although dengue symptoms and complications have been known for many decades, there has only been one documented case of osteonecrosis of the maxilla which was treated by excision of the necrotic bone. In this case of dengue infection, extensive maxillary osteonecrosis and minimal root resorption appeared to follow factitious injury with a toothpick but resolved with non-surgical management.

Matched MeSH terms: Osteonecrosis/complications*; Osteonecrosis/virology
Fulltext Risk factors for symptomatic Avascular Necrosis (AVN) in a multi-ethnic Systemic Lupus Erythematosus (SLE) cohort

Shaharir SS, Chua SH, Mohd R, Mustafar R, Noh MM, Shahril NS, et al.

PLoS One, 2021;16(3):e0248845.
PMID: 33739994 DOI: 10.1371/journal.pone.0248845

Avascular necrosis of bone (AVN) is increasingly being recognized as a complication of SLE and causes significant disability due to pain and mobility limitations. We studied the prevalence and factors associated with avascular necrosis (AVN) in a multiethnic SLE cohort. SLE patients who visited the outpatient clinic from October 2017 to April 2019 were considered eligible. Their medical records were reviewed to identify patients who developed symptomatic AVN, as confirmed by either magnetic resonance imaging or plain radiography. Subsequently, their SLE disease characteristics and treatment were compared with the characteristics of patients who did not have AVN. Multivariable logistic regression analyses were performed to determine the independent factors associated with AVN among the multiethnic SLE cohort. A total of 390 patients were recruited, and the majority of them were females (92.6%); the patients were predominantly of Malay ethnicity (59.5%), followed by Chinese (35.9%) and Indian (4.6%). The prevalence of symptomatic AVN was 14.1%, and the mean age of AVN diagnosis was 37.6 ± 14.4 years. Both univariate and multivariable logistic regression analyses revealed that a longer disease duration, high LDL-C (low density lipoprotein cholesterol), positive anti-cardiolipin (aCL) IgG and anti-dsDNA results, a history of an oral prednisolone dose of more than 30 mg daily for at least 4 weeks and osteoporotic fractures were significantly associated with AVN. On the other hand, hydroxychloroquin (HCQ), mycophenolate mofetil (MMF) and bisphosphonate use were associated with a lower risk of AVN. No associations with ethnicity were found. In conclusion, several modifiable risk factors were found to be associated with AVN, and these factors may be used to identify patients who are at high risk of developing such complications. The potential protective effects of HCQ, MMF and bisphosphonates warrant additional studies.

Matched MeSH terms: Osteonecrosis/complications*; Osteonecrosis/epidemiology*
Fulltext Application of platelet rich fibrin for management of an electrosurge induced osteonecrosis involving maxillary alveolus

Suresh N, Chandrasekaran B, Muthusamy S, Kannan S, Muthu K

Singapore Dent J, 2015 Dec;36:39-43.
PMID: 26684495 DOI: 10.1016/j.sdj.2014.11.004

BACKGROUND: Application of principles of electrocautery for hemostasis dates back to prehistoric times. Its modern implementation in various fields of general and head and neck surgeries have been well documented. However its usage in minor oral surgical procedures has gained popularity only recently. Complications associated with electro-surgery in the dental field are relatively rare and there is insufficient literature on its management.
CASE REPORT: We present a case report on management of an electrosurgery induced osteonecrosis involving maxillary alveolus of left premolars.
DISCUSSION: Inadvertent contact of the electrosurgery tip on bone can result in necrosis making it necessary to remove the sequestrum and graft the defect. Platelet rich fibrin in combination with bone grafts have been well documented to provide successful periodontal regeneration.
CLINICAL IMPLICATIONS: Our aim of presenting this report is to create awareness among the health care providers regarding electrosurgical injuries. To our knowledge, this is the first time platelet rich fibrin has been used in the management of intraoral electrosurgical injury. Combining bone grafts with platelet rich fibrin is a good alternative as it can be done with relative ease and predictable outcome.

Matched MeSH terms: Osteonecrosis
Fulltext Cannulated Screw Fixation For Femoral Neck Fractures : A 5-year Experience In A Single Institution

Khoo C, Haseeb A, Ajit Singh V

Malays Orthop J, 2014 Jul;8(2):14-21.
PMID: 25279087 DOI: 10.5704/MOJ.1407.010

Cannulated screw fixation is a widely accepted surgical method for management of fractures of the neck of femur especially in patients with poor premorbid conditions, minimally displaced fractures and those from a younger age group. A five year retrospective study was carried out in 53 consecutive patients between 2006 to 2010 to determine the pattern of injuries, management, outcomes and the associated predictive factors.All the patients underwent cannulated screw fixation, with 37 (69.8%) having had surgery within 24 hours and the remaining 16 (30.2%) 24 hours after the initial injury. All patients were followed up to union of fractures and complications thereafter if any. Good outcome was observed in 43 (81.1%) patients leaving only 10 (18.9%) patients with a poor outcome, of whom nine developed avascular necrosis (90%) and one non-union (10%). We found no significant relationship between the incidence of avascular necrosis and age of patient, fracture displacement, numbers of cannulated screws used, fracture reduction acceptability and anatomical location of the fracture. The time interval from injury to surgery and the presence of posterior comminution did seem to influence the rate of avascular necrosis but due to the small number of patients, was not statistically significant.We conclude that cannulated screw fixation is a viable option of treatment for fractures of the neck of femur.

Matched MeSH terms: Osteonecrosis
Bisphosphonates, healthcare professionals and oral health

Raj DV, Abuzar M, Borromeo GL

Gerodontology, 2016 Mar;33(1):135-43.
PMID: 25039439 DOI: 10.1111/ger.12141

OBJECTIVE: General medical and dental practitioner and pharmacists all encounter patients on bisphosphonates and as such require adequate knowledge regarding osteonecrosis of the jaw, a potential complication associated with its use. The cross-sectional study investigated perceived implications of and attitudes towards bisphosphonate use in oral health among general medical and dental practitioners and pharmacists.
MATERIALS AND METHODS: Medical and dental practitioners and pharmacists registered in Victoria, Australia, completed an online survey (SurveyMonkey©). Data analysis consisted of chi-square tests with significance as p < 0.05.
RESULTS: One hundred and thirty six doctors (general medical practitioners, GMPs), 283 dentists (GDPs) and 26 pharmacists (PHs) participated. 70, 38 and 80%, respectively, reviewed patients prescribed bisphosphonates (BPs). GMPs (88%), GDPs (76%) and PHs (85%) were aware of osteonecrosis of the jaws (ONJ). GMPs (76%) and PHs (100%) advised patients to inform dentists. GMPs (45%) referred patients for dental assessments prior to commencing BPs with 71.9% of GDPs received such referrals. In terms of available information on oral health and BPs, GMPs (56%), GDPs (50%) and PH (53.8%) were either unsure any existed or reported receiving sufficient information.
CONCLUSIONS: Discrepancies exist amongst different healthcare professionals in terms of BP use and oral health, and common consensus guidelines are warranted.
KEYWORDS: bisphosphonates; clinical guidelines; drug therapy; oral health; osteonecrosis.

Matched MeSH terms: Osteonecrosis/drug therapy; Osteonecrosis/prevention & control; Bisphosphonate-Associated Osteonecrosis of the Jaw/prevention & control
Osteonecrosis with renal damage in HIV patients undergoing HAART

Chitra P, Bakthavatsalam B, Palvannan T

Biomed Pharmacother, 2014 Sep;68(7):881-5.
PMID: 25194446 DOI: 10.1016/j.biopha.2014.07.017

Rheumatoid arthritis in HIV patients undergoing HAART is associated with increased risk of side effect. Elevation of uric acid (UA) is important in tissue damage, deposition of crystal in joints leads to the development of rheumatoid arthritis in the HAART complaint group. This study was carried out to investigate the relationship of uric acid, RA factor, ANA, ESR, cystatin C, urea and creatinine in the HAART complaint group. Moreover; the ratio of uric acid/cystatin C, uric acid/urea and uric acid/creatinine were also studied. To analyze the progression of HIV, the immunological parameters were correlated with uric acid. Our result showed a statistically high significant increase in uric acid, RA factor, ANA, ESR, cystatin C, urea and creatinine in the HAART complaint group when compared to HAART non-complaint group, early stage and control. The ratio of uric acid/cystatin C, uric acid/urea, uric acid/creatinine were significantly increased in the HAART complaint group. Statistically significant positive correlation was observed between uric acid and cystatin C, urea, creatinine, absolute CD4 and CD8 count. The increased level of uric acid, RA factor, ANA, ESR, cystatin C and increased ratio of uric acid/cystatin C in the HAART complaint group might conclude the mechanism underlying the increased risk for rheumatoid arthritis in the HAART complaint group which may relate to the combined effects of low-grade inflammation and renal dysfunction.

Study done in India

Matched MeSH terms: Osteonecrosis/chemically induced*; Osteonecrosis/metabolism
Fulltext Outcome of longstanding dislocated elbows treated by open reduction and excision of collateral ligaments

Devnani AS

Singapore Med J, 2004 Jan;45(1):14-9.
PMID: 14976577

To study the long term result of open reduction of longstanding dislocated elbows with regard to stability, avascular necrosis of the distal humerus and degenerative changes of the joint.

Matched MeSH terms: Osteonecrosis/etiology*; Osteonecrosis/radiography
Fulltext Management of osteonecrosis of the hip complicated with fracture: a case report

Chua Y, Wazir N, Chiu C, Kareem B

Malays Orthop J, 2012 Jun;6(SupplA):43-5.
PMID: 25279075 MyJurnal DOI: 10.5704/MOJ.1211.011

A 47-year-old gentleman, with underlying seborrhoeic dermatitis that was treated with steroid therapy, and hepatitis B, presented with pain in his right hip. He was diagnosed with stage 2 osteonecrosis of the right hip (Ficat and Arlet classification). Core decompression and bone grafting was performed but recovery was complicated by a surgical site infection. Wound debridement, removal of bone graft and clearance of the bone tunnel were carried out. The patient was allowed to bear weight after surgery. Twelve days later, he developed right hip pain and radiographs showed fractured femur neck; the patient then underwent a two-stage total hip replacement (THR).

Matched MeSH terms: Osteonecrosis
Fulltext Intra- and Inter-observer Variability in Different Methods of Measuring Carpal Collapse

Agrawal S, Chabra T, Pandey S, Bhardwaj P

Malays Orthop J, 2019 Mar;13(1):20-24.
PMID: 31001379 DOI: 10.5704/MOJ.1903.003

Introduction: Carpal collapse of wrist occurs in disorders like rheumatoid arthritis and Kienbock's disease. Three techniques have been described to measure carpal collapse. First, the carpal height ratio (CHR), measured by dividing carpal height by 3rd metacarpal length. Second, the revised carpal height ratio (RCH ratio), measured by dividing carpal height by length of capitate. Third, capitate radius distance (CR index), measured by shortest distance between distal edge of radius and the proximal edge of capitate. The index publications describe good reliability of all these but which method out of the three is best in terms of intra- and inter-observer variability is not known. The purpose of this study was to find out which method had the least inter- and intra-observer variability for determining carpal collapse. Materials and Methods: Fifty normal wrist postero-anterior radiographs were studied by three assessors who measured CHR, RCH ratio and CR index separately. The measurements were repeated after one month by all the three observers. The results were then statistically analysed. Results: The p-value was <0.001 in all the three assessors in CR index meaning that the intra-observer variability was least in CR index. For the inter-observer variability intra class coefficient of 0.9 indicated that the CR index has the least variability. Conclusion: CR index is the most reproducible method to measure carpal collapse. The method which provides accurate measurement of carpal collapse will allow better staging of carpal disorders.

Study site: Grande Hospital, Nepal

Matched MeSH terms: Osteonecrosis
Fulltext Incarcerated Cannulated Cancellous Screw Removal during Total Hip Arthroplasty with a Novel Trick: A Case Report

Tomar L, Govil G, Dhawan P

Malays Orthop J, 2021 Mar;15(1):128-131.
PMID: 33880160 DOI: 10.5704/MOJ.2103.020

Salvage total hip arthroplasty (THA) may be required to manage femoral neck fracture implant failures, avascular necrosis and secondary hip arthritis. Cannulated cancellous screws can become stripped or incarcerated during the initial implantation and pose hardware removal issues. We present a novel technique for safe screw removal in a 62-year-old female patient with a painful right hip. She had undergone cancellous screw fixation for a fracture of the neck of femur ten years ago. There was avascular necrosis with screw cut out leading to secondary hip arthritis necessitating THA. Intra-operatively cannulated cancellous screw along the inferior femoral neck region was incarcerated. After posterior dislocation of the head, the neck was osteotomised, and the screw threads were exposed for possible extraction. However, the thickened femoral neck region with solid cortical bone prevented the screw disengagement in either direction. The screw along the femoral trochanter region was cut with a Harrington cutter and the remaining screw disengaged with careful removal of bony spicules and controlled anticlockwise rotations, to remove the screw in around fifteen minutes. Arthroplasty could be completed uneventfully thereafter. We could remove the screw while avoiding an iatrogenic fracture along the calcar region and excessive bone loss along the screw track. The femoral canal remained uncompromised. The anticipation of a difficult implant removal with a thorough understanding of the devices and techniques, is an invaluable asset to the operating surgeon. With a simple tool and novel technique in a difficult situation, we can save on operating time and minimise complications.

Matched MeSH terms: Osteonecrosis
Fulltext Aviator's Fracture - Bilateral Fracture-Dislocation of Talus in a 29-year-old Patient: A Case Report

Noia G, Silluzio N, Sircana G, Maccauro G, Ziranu A

Malays Orthop J, 2019 Nov;13(3):80-84.
PMID: 31890117 DOI: 10.5704/MOJ.1911.015

Bilateral fracture-dislocation of the talus is a rare occurrence. It represents 0.06% of the dislocations and 2% of the traumas of the talus. We report the case of a 29-year-old patient with an exposed bilateral fracture of the talus following a plane accident. On the right ankle, the patient had a fracture-dislocation Hawkin 3 Gustilo II, on the left ankle presented a Hawkin 4 Gustilo IIIB. The patient was treated within six hours from the trauma. We reduced the dislocation and performed an osteotomy of the tibial malleolus and osteosynthesis of the fracture with screws. The definitive stabilisation has been achieved in both limbs with an external fixator. We evaluated the patient at 1, 3, 6, 8, 12 and 18 months from treatment, with a radiograph and with SF-36 and Foot and Ankle Disability Index questionnaires. No infection was reported, radiographs showed a successful consolidation of the fracture in both limbs. At the one year follow-up, the patient was able to walk without aids and there were no signs of osteonecrosis on the MRI. The treatment of these lesions requires timely treatment, an anatomical reduction of the fracture and patient's collaboration. The use of external fixator with internal osteosynthesis represents a good therapeutic option in Hawkins 3 and 4 type fractures.

Matched MeSH terms: Osteonecrosis
Fulltext Transient Osteoporosis of the Hip: A Case Report

Pande K, Aung TT, Leong JF, Bickle I

Malays Orthop J, 2017 Mar;11(1):77-78.
PMID: 28435582 DOI: 10.5704/MOJ.1703.012

Transient osteoporosis of the hip (TOH) is a benign, selflimiting condition characterised by acute onset groin pain in adults. Early diagnosis is important to differentiate it from progressive conditions such as osteonecrosis. We report on a middle-aged male who presented with right groin pain without any prior trauma. The diagnosis of transient osteoporosis of hip was confirmed by Magnetic Resonance Imaging (MRI) and he was successfully treated with a course of Alendronate sodium, anti-inflammatory analgesics and a period of non-weight bearing ambulation.

Matched MeSH terms: Osteonecrosis
Fulltext Avascular Necrosis of the Hip in Primary Care

Baharum NN, Ariffin F, Hanafiah M, Sulaiman SH

Korean J Fam Med, 2021 Jan;42(1):84-87.
PMID: 32447880 DOI: 10.4082/kjfm.19.0021

Avascular necrosis, or osteonecrosis of the femoral head, is a debilitating condition which leads to the destruction of the hip joint due to an interruption in the blood supply to the bony region and is most commonly due to trauma. The case discussed here has been highlighted as it presented as non-traumatic osteonecrosis of the femoral head with an absence of risk factors in a healthy adult male. A 37-year-old male presented with a 4-month history of recurrent left hip pain, which worsened with initiation of movement and weightbearing on the affected side. The patient was overweight but normotensive with a full range of movement of the hips bilaterally. There were no abnormalities detected on initial X-ray images of the left hip. However, due to the persistent pain and sclerotic changes in a subsequent X-ray, a magnetic resonance image of the bilateral hips was obtained, leading to the diagnosis of osteonecrosis of the bilateral femoral heads. Due to the lack of improvement with physiotherapy and analgesia, the patient was subjected to conservative surgery of the symptomatic left hip with concurring evidence of avascular necrosis based on intraoperative anatomical biopsy. This case emphasizes the importance of identifying underlying issues during history taking and physical examination in adults without risk factors. The early diagnosis of osteonecrosis assists in preventing joint collapse and can delay the requirement of joint replacements. High levels of suspicion are necessary to instigate investigation in persistent cases without the presence of risk factors.

Matched MeSH terms: Osteonecrosis

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