Introduction: Osteonecrosis is a devastating disease which can affect multiple joints including the distal radius. Although there are a number of studies that have reported the clinical outcomes of patients treated for osteonecrosis of the hip, knee, shoulder, and other locations, there are no known studies that have evaluated the outcome of patients who have this disease in the distal radius. The purpose of this study was to assess the characteristics of atraumatic, symptomatic osteonecrosis of the distal radius. In addition, based on reports that have shown the safe and effective use of core decompressions to treat early stages of osteonecrosis in other joints, we assessed whether this treatment modality also would provide pain relief and delay progression of the disease in the distal radius.

Methods: A review of 434 osteonecrosis patient records from the past 7 years in our prospectively collected database identified 4 patients (6 wrists) who had the disease in the distal radius. Two of these patients also had the disease in the ulna. All 4 patients were women, and their mean age was 46 years (range, 37 to 52 years). Clinical and radiographic outcomes were assessed at a mean of 39 months (range, 12 to 84) following treatment with core decompression. The clinical evaluations were conducted using the Michigan Hand Outcomes Questionnaire (MHQ). The reported pre-operative MHQ component scores for function, completion of everyday activities, pain, completion of work activities, overall appearance of the hands, and patient satisfaction were compared to the results of the MHQ at final follow-up. Radiographic success of the core decompressions was based on whether there was any progression in the stage of the disease.

Results: The most common risk factor for this cohort of patients was corticosteroids with 3 of the 4 patients having reported prior use. Other risk factors included alcohol consumption on a regular basis (n = 2), tobacco abuse (n = 2), blood dyscrasia (n = 2), and systemic lupus erythematosus (n = 1). Additionally, all 4 patients had multifocal osteonecrosis (affecting at least four separate anatomic sites. Overall, the patients reported a mean improvement in MHQ score (from 65% to 84%). Stratified by category, satisfaction improved from 64% to 88%, overall hand function increased from 64% to 81%, and pain was reduced from 60% to 25%, for pre- and post-operative values, respectively. One patient (2 wrists) required additional core decompressions in each wrist at one year following surgery but reported sustained improvement in her MHQ for both wrists at two years following her second core decompressions. There were no complications associated with the core decompressions, and there was no radiographic progression in the stage of the disease in any of the cases.

Discussion: Osteonecrosis of the distal radius is rarely found in patients with this disease (< 1%). It can be found in patients with osteonecrosis of other joints who have a symptomatic wrist and may have more than one risk factor. It can be readily diagnosed with x-rays and/or MRI. The results of the present study suggest that core decompression is a safe and effective treatment modality for symptomatic osteonecrosis of the wrist at the distal radius and/or ulna. Although the level of improvement in MHQ varied for each case, all patients reported reduced pain and improved function at final follow-up without any apparent complications. Based on these results, we recommend the use of core decompressions to alleviate the symptoms and to possibly delay the progression of distal radius osteonecrosis.

Introduction: Osteonecrosis of the hip is a devastating disease that often results in the collapse of the femoral head and secondary osteoarthritis of the hip. Although total hip arthroplasty is considered the main therapeutic option in cases of advanced osteonecrosis (Ficat stage III or IV), historically high failure rates have been reported for this treatment. Variables such as, whether or not the prosthesis was cemented, year of implantation, age, various medical comorbidities, and risk factors such as alcohol abuse, corticosteroids usage, autoimmune disease, or sickle cell anemia may lead to better or worse outcomes. The purpose of this study was to determine which factors were associated with risk for failure concerning total hip arthroplasty (THA) for osteonecrosis of the femoral head from a complete meta-analysis of the literature.

Methods: A systematic review utilizing the Medline bibliographic database found 35 studies meeting our inclusion criteria that were related to osteonecrosis encompassing 557 hips in 443 patients. These reports were published between the years 1989 to 2007. The mean follow-up was 6.7 years (range, 3 – 10). The study population comprised of 60% men who had a mean age of 47 years (range, 17 to 90). The most frequent associated risk factors for osteonecrosis were corticosteroid usage (26.2%) and alcohol abuse (30.1%). The final outcome parameters were number and percentage of patients who underwent revision surgery, who had impending radiographic failure, such as osteolytic lesions in close proximity to the implant, or who were clinical failures. Clinical failure was defined as a value less than 70% of the maximum score of the relevant hip scoring system used.

All reviewed studies were divided into cemented, cementless, or hybrid fixation, as well as year of implantation (before and after 1990). In addition, patients were stratified according to comorbidities, age, gender, and various diagnostic and other risk factors (e.g. systemic lupus erythematosus, sickle cell disease, use of corticosteroids, alcohol abuse).

Results: Overall, there were 131 poor outcomes out of 557 hips (23.5%). Seventy-six revision surgeries were performed, with another 55 hips showing either radiographic signs of loosening or clinical failures. Cemented THA had a failure rate of 17.9%, while the cementless THA had a failure rate of 24.5%.

Overall outcomes were different for various risk factors; intake of corticosteroids led to a failure rate of 42.3%, alcohol abuse; 38.1%, posttraumatic disorders; 39%, and sickle cell anemia; 45.5%. Patients without known adverse risk factors had only 17% failures.

Discussion: Our findings further emphasize the poor results of total hip arthroplasty in patients with various risk factors such as alcohol abuse, use of corticosteroids, lupus, and sickle cell anemia. It also appears that patients without these adverse risk factors have a better survival rate. The importance of this study is that it may help the surgeon understand the risk of total hip arthroplasty in various stratified groups in patients with osteonecrosis.