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Spontaneous Resolution of Osteonecrosis of the Femoral Head
Edward Y. Cheng, MD1; Issada Thongtrangan, MD1; Alan Laorr, MD3; Khaled J. Saleh2
1 Department of Orthopaedic Surgery and Clinical Outcomes Research Center, University of Minnesota, 2450 Riverside Avenue South, R200, Minneapolis, MN 55454. E-mail address for E.Y. Cheng: cheng002@umn.edu
3 Suburban Radiologic Consultants, 4801 West 81st Street, Suite 108, Minneapolis, MN 55437
2 Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Charlottesville, VA 22903
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A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health (2P0IDK13083-300219), the Minnesota Medical Foundation (BE-3-96), and Smith and Nephew. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Smith and Nephew) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery and Clinical Outcomes Research Center, University of Minnesota, Minneapolis, Minnesota

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Dec 01;86(12):2594-2599
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Abstract

Background: The decision to proceed with surgical treatment of asymptomatic osteonecrosis of the femoral head is controversial. The purpose of the present study was to determine (1) if spontaneous resolution of osteonecrosis of the femoral head occurs, (2) how long it takes for resolution to occur, and (3) if there are predictors of spontaneous resolution.

Methods: Patients with asymptomatic osteonecrosis of the femoral head were identified from two National Institutes of Health-funded screening studies: a prospective screening study for osteonecrosis of the femoral head after organ transplantation and a study in which patients who had had surgical treatment of symptomatic osteonecrosis of the femoral head were screened for osteonecrosis of the contralateral, asymptomatic hip. The cohort of patients with asymptomatic osteonecrosis of the femoral head was then analyzed.

Results: Thirteen asymptomatic hips in ten patients were identified in the prospective screening study for osteonecrosis after organ transplantation, and seventeen hips in seventeen patients were identified in the contralateral hip-screening study. Three hips, all from the group of patients who had had organ transplantation, had Association Research Circulation Osseous stage-I disease with spontaneous resolution occurring later as evidenced by serial magnetic resonance imaging scans. In these three hips, the modified index of necrotic extent measured 11.10, 12.72, and 20.83, with the estimated percentage of femoral head involvement being 15% to 30% in two of the hips and <15% in the third. Resolution on magnetic resonance imaging was complete in two of the three hips and was nearly complete in the third. Resolution was not observed when the contralateral hip had symptomatic disease.

Conclusions: Spontaneous resolution of osteonecrosis of the femoral head can occur. The factors that appear to be related to resolution are early, asymptomatic disease (Association Research Circulation Osseous stage I) and small lesion size (a modified index of necrotic extent of <25). A larger series is necessary before these factors can be verified as being independent predictors of resolution. Initial signs of resolution may take as long as one year to occur.

Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Satoshi Iida
    Posted on March 30, 2005
    Spontaneous Resolution of Osteonecrosis of the Femoral Head
    Mastudo City Hospital, 4005 Kamihongou Mastudo-city, Chiba,Japan

    To the Editor:

    We read with great interest thr article by Cheng et al.(1). We agree with the authors that early and asymptomatic osteonecrosis has a possibility of spontaneous resolution and have reported spontaneous resolution in large necrotic lesions which impinged on two-thirds or more of the weight bearing portion of the acetabulum (2). We reported that the initial MR abnormalities indicating oseonecrosis were seen between 2 and 4 months after the initiation of steroid therapy(2).

    In the article by Cheng, et al(1), the interval between the transplantation and the initial diagnosis of osteonecrosis was between four and seven months. We speculate that spontaneous resolution in the authors' cases had already begun at the time of their initial diagnosis and that the initial sizes of the necrotic lesions might have been larger before they were detected by the authors.

    Large necrotic lesions have been reported to tend to collapse and spontaneous resolution may not develop after collapse. Subchondral fracture in the necrotic area leads to abnormal distribution of weight-bearing forces, and altered weight- bearing may cause abnormal mechanical stress on the demarcated zone and surrounding healthy bone(3).

    Even if necrotic lesions are large, they have the potential to resolve spontaneously, so long as there is a normal mechanical distribution of weght-bearing forces, but subchondral fractures can develop in association with minor trauma. We think that for the prevention of collapse, it is important to advise patients with these lesions not to do strenuous activities.

    References:

    1.Edward Y. Cheng, Issada Thongtrangan, Alan Laorr, and Khaled J. Saleh Spontaneous Resolution of Osteonecrosis of the Femoral Head J Bone Joint Surg Am 2004; 86: 2594-2599

    2. Sakamoto M, Shimizu K, Iida S, Akita T, Moriya H, Nawata Y. Osteonecrosis of the femoral head(a prospective study with MRI). J Bone joint Surg Br, 1997;79:213-219.

    3. Iida S, Harada Y, Shimizu K, Sakamoto M, Ikenoue S, Akita T, Kitahara H, Moriya H. Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis. AJR, 2000;174:735- 743.

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