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Long COVID is a term used to describe the long-terms effects of COVID-19 infection that continue for weeks or months after the patient has recovered from COVID-19. Long COVID is defined by the persistence of symptoms beyond 12 weeks from the onset of the disease. Corticosteroids are part of the treatment in this period with good results in controlling the disease; however, it is a predisposing factor for the development of avascular necrosis. We present a clinic case of a young man of 39 years old with diagnosis of avascular necrosis in his left hip, before the administration of corticosteroids for the treatment of COVID-19. There is a lack of consensus about the dosage and duration of steroids required to develop avascular necrosis. Some authors have reported that cumulative dose of 2,000 mg prednisone (or its equivalent) was required for avascular necrosis development. For patients with advanced avascular necrosis stages total hip arthroplasty is an attractive option with excellent outcomes in terms of pain relief and survivorship.

El COVID de larga duración es un término que describe la enfermedad en pacientes que se recuperaron de una infección por COVID-19 y reportan síntomas por más de 12 semanas. Los corticosteroides forman parte del tratamiento en este período con buenos resultados en el control de la enfermedad; sin embargo, el uso de este grupo de medicamentos se ha descrito como un factor de riesgo para el desarrollo de necrosis avascular. Se describe el caso clínico de un paciente masculino de 39 años con diagnóstico de necrosis avascular de la cadera izquierda posterior a la administración de corticosteroides para el tratamiento de COVID-19. La dosis de esteroides capaz de provocar necrosis avascular no está clara o bien descrita; sin embargo, existen reportes en la literatura donde se habla de dosis de 2,000 mg de prednisona (o equivalentes) para su desarrollo. El tratamiento de la necrosis avascular tiene como objetivo el alivio del dolor, retardar la progresión del cuadro, prevenir el colapso en etapas tempranas y restaurar la función articular. La artroplastía o recambio total de cadera parece ser una excelente opción de tratamiento quirúrgico para aquellos pacientes en etapas avanzadas.

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BACKGROUND: Avascular necrosis (AVN) remains the most dreaded complication of unstable slipped capital femoral epiphysis (SCFE) treatment. Newer closed reduction techniques (with perfusion monitoring) have emerged as a technically straightforward means to address residual SCFE deformity while still minimizing the risk of osteonecrosis. However, limited data exists regarding the reliability of intraoperative epiphyseal perfusion monitoring to predict the development of AVN. The purpose of this study was to evaluate its reliability. METHODS: We retrospectively reviewed all patients with unstable SCFE who underwent closed or open reduction with epiphyseal perfusion monitoring using an intracranial pressure (ICP) probe from 2015 to 2023 at a single institution with a minimum 6-month radiographic follow-up. Demographic, clinical, and radiographic data were recorded, including duration of symptoms, type of reduction, capsulotomy performed, presence of a waveform on ICP monitoring after epiphyseal fixation, and development of AVN on follow-up radiographs. RESULTS: Our cohort included 33 hips (32 patients), of which 60.6% (n=20) were male. The average age was 12.5±1.8 years, with a median follow-up of 15.8 months. Eleven hips were treated with open reduction using the modified Dunn technique (10 hips) or anterior approach (1 hip), and 22 hips were treated with inadvertent (5 hips) or purposeful closed reduction using the Leadbetter technique (17 hips). Overall, 8 of the 33 hips in our series (24.2%) developed AVN, 6 of which (20%) had a pulsatile waveform on intraoperative epiphyseal perfusion monitoring. The overall rate of AVN after closed reductions was 31.8% (7 of 22 hips); the incidence of AVN after closed reduction with a detectable waveform was 30% (6 of 20 hips). There was no significant association between time to surgery ( P =0.416) or type of reduction ( P =0.218) and the incidence of AVN. CONCLUSIONS: In this series, intraoperative epiphyseal perfusion monitoring did not reliably predict the development of osteonecrosis. To our knowledge, this is the first study to report AVN after demonstrable intraoperative epiphyseal perfusion following closed reduction of unstable slips. LEVEL OF EVIDENCE: Level IV: case series-therapeutic study.

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Abstract Objective Testing an experimental model for ischemic necrosis of the femoral head in Legg-Calvé-Perthes disease by evaluating gait, imaging and morphohistology. Methods The operation was done in 11 piglets. Necrosis by cerclage in the right femoral neck was induced. Piglets were divided into group A, with 8 animals, euthanizing two in the 2nd, 4th, 6th, and 8th weeks, respectively; and group B, with 2 animals (sham), submitted to the surgical procedure without cerclage of the right femoral neck. The gait classification used was that of Etterlin. The frozen femurs were submitted to digital radiography and computed tomography. The height and width of the epiphysis and epiphysary coefficient were measured at study times. Light microscopy and immunohistochemistry with TGF-β1 were performed. Results One animal died of sepsis in Group A. In this group, claudication was observed in all animals. On digital radiography and computed tomography, bone sclerosis, enlargement of the right femoral neck, flattening, collapse, and fragmentation of the right femoral head were observed. All epiphysis height and epiphysary coefficient values of the right femoral head were lower than the contralateral ones, in which were observed chondrocytes disordered and separated by gaps. A reduction in TGF-β1 expression was observed at 2 and 6 weeks in the right femoral head and at eight in the left. In group B, there were no signs of necrosis and gait was normal. Conclusions The model presented reproduced macroscopic necrosis on digital radiography, computed tomography, and microscopy. Gait evaluation showed a good correlation with other ischemia findings. Level of EvidenceV. Diagnostic studies.

Resumo Objetivo Testar um modelo experimental para necrose isquêmica da cabeça femoral na doença de Legg-Calvé-Perthes avaliando a marcha, exames de imagens e morfohistologia. Métodos Operaram-se 11 leitões. Induziu-se a necrose por cerclagem no colo femoral direito. Dividiram-se os leitões em grupo A com 8 animais, sacrificando-se dois na 2ª, 4ª, 6ª e 8ª semanas, respectivamente; e grupo B, com 2 animais (sham), submetidos ao procedimento cirúrgico sem a cerclagem do colo femoral direito. A classificação da marcha utilizada foi a de Etterlin. Os fêmures congelados foram submetidos à radiografia digital e tomografia computadorizada. Mediram-se a altura e largura da epífise e o coeficiente epifisário nos tempos de estudo. Realizou-se, microscopia de luz e imunohistoquímica com TGF-β1. Resultados Um animal morreu por sepse no grupo A. Neste grupo, observou-se claudicação em todos os animais. Na radiografia digital e tomografia computadorizada observaram-se: esclerose óssea, alargamento do colo femoral direito, achatamento, colapso e fragmentação da cabeça femoral direita. Todos os valores da altura da epífise e coeficiente epifisário da cabeça femoral direita foram menores que os contralaterais, nos quais observaram-se condrócitos desordenados e separados por lacunas. Observou-se redução da expressão do TGF-β1 com 2 e 6 semanas nas cabeças femorais direitas e nas esquerdas com oito. No grupo B, não ocorreram sinais de necrose e a marcha foi normal. Conclusões O modelo apresentado reproduziu a necrose macroscopicamente, na radiografia digital, tomografia computadorizada e microscopia. A avaliação da marcha demonstrou boa correlação com os demais achados de isquemia. Nível de EvidênciaV. Estudos diagnósticos.

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Resumen La drepanocitosis o anemia de células falciformes es una hemoglobinopatía hereditaria que se transmite de forma autosómica recesiva, la cual está asociada con episodios de dolor agudo y daño progresivo a órganos blanco que producen un gran impacto en la esperanza y la calidad de vida de quienes la padecen. La necrosis avascular de la cabeza del fémur es una complicación bien conocida en los pacientes con drepanocitosis presente hasta en un 25 % de los pacientes adultos y tanto en un 12 % de los pacientes pediátricos. A continuación, se presenta el caso de un paciente masculino de 9 años con drepanocitosis, quien en cita de control refirió 15 días de coxalgia y claudicación de la marcha. Tras realizar estudios radiológicos se documentó una necrosis avascular de la cabeza del fémur, convirtiéndose de esta manera en el primer caso documentado en el Hospital Nacional de Niños de Costa Rica de un paciente pediátrico con una necrosis avascular de la cadera del fémur como complicación de su drepanocitosis.

Sickle cell disease is an autosomic recessive hereditary hemoglobin disorder, associated with episodes of acute pain and progressive organ damage with great impact on a patient's life expectancy and quality of life. Avascular necrosis of the femoral head is a well-known complication of sickle cell disease affecting almost 25% of adult patients and just in 12% of pediatric patients. Below is the case of a 9-year-old male patient with sickle cell disease, who on a control appointment reported 15 days of hip pain and gait claudication. After performing radiological studies, avascular necrosis of the femoral head was diagnosed, becoming the first case documented at the National Children Hospital of Costa Rica of avascular necrosis of the femoral head as a complication in a pediatric patient with sickle cell disease.

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Abstract Objective To evaluate the safety and reproducibility of the surgery for unstable slipped capital femoral epiphysis (SCFE) through the modified Dunn technique in a single center cohort from Brazil. Methods We retrospectively analyzed a cohort of patients submitted to this procedure by a single surgeon who was a hip preservation specialist. Demographic data and radiographic angles were evaluated for the relative risk (RR) of avascular necrosis (AVN) using a log-binomial regression model with simple and random effects. Results Among the 30 patients (30 hips) with a mean age of 11.79 years at the time of the operation, there were 17 boys and 18 left hips, which were operated on in a mean of 11.5 days after the slip. The mean follow-up was of 38 months. The preoperative Southwick angle averaged 60.69° against 4.52° postoperatively (p< 0.001). A larger preoperative slip angle was associated with the development of AVN (RR: 1.05; 95% confidence interval [95%CI]: 1.02-1.07; p< 0.01). The overall AVN rate was of 26.7%. Function was good or excellent in 86% of uncomplicated hips, and poor in 87.5% of the partients who developed AVN, as graded by the Harris Hip Score. There was no statistical relationship between epiphyseal bleeding and AVN development (p= 0.82). Conclusion The modified Dunn technique is associated with restoration of the femoral alignment and function after unstable SCFE, when uncomplicated. Moreover, it was shown to be reproducible in our population, with a rate of 26% of femoral head necrosis.

Resumo Objetivo Avaliar a segurança e a reprodutibilidade da cirurgia para escorregamento da epífise femoral proximal (EEPF) com instabilidade por meio da técnica de Dunn modificada em uma coorte unicêntrica no Brasil. Métodos Analisamos de forma retrospectiva uma coorte de pacientes submetidos a esse procedimento por um único cirurgião especialista em preservação do quadril. Avaliamos os dados demográficos e os ângulos radiográficos quanto ao risco relativo (RR) de necrose avascular (NAV) por meio do modelo de regressão log-binomial com efeitos simples e aleatórios. Resultados Entre os 30 pacientes (30 quadris) com idade média de 11,79 anos no momento da cirurgia, havia 17 meninos e 18 quadris esquerdos. O procedimento ocorreu em média 11,5 dias após o escorregamento. O tempo médio de acompanhamento foi de 38 meses. O ângulo de Southwick pré-operatório foi, em média, de 60,69° contra 4,52° após o procedimento (p< 0,001). O maior ângulo de escorregamento pré-operatório foi associado ao desenvolvimento de NAV (RR: 1,05; intervalo de confiança de 95% [IC95%]: 1,02-1,07; p< 0,01). A frequência geral de NAV foi de 26,7%. De acordo com a Escala de Quadril de Harris (Harris Hip Score), a função foi boa ou excelente em 86% dos quadris sem complicações, e ruim em 87,5% dos casos com NAV. Não houve relação estatística entre sangramento epifisário e desenvolvimento de NAV (p= 0,82). Conclusão A técnica de Dunn modificada restaura o alinhamento femoral e a função articular após o EEPF com instabilidade na ausência de complicações. Além disso, mostrou-se passível de reprodução em nossa população, com frequência de necrose da cabeça femoral de 26%.

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Abstract Objectives Although osteonecrosis of the femoral head is a prevalent condition, its effects on gait parameters have not been thoroughly studied and are not well-established in the current literature. The primary aim of the present study is to describe gait in patients with a diagnosis of osteonecrosis. Methods This is a cross-sectional study. Nine patients diagnosed with osteonecrosis of the femoral head who were regularly followed-up at an outpatient clinic were selected for the present study and underwent gait analysis using Vicon Motion Capture Systems. Spatiotemporal data was obtained, and joint angles were calculated using an Euler angle coordinate system. Distal coordinate systems were used to calculate joint momentsand forceplatestoobtaingroundreactionforces. Results Patients with osteonecrosis presented with slower velocity (0.54 m/s ± 0.19) and smaller cadence (83.01 steps/min ± 13.23) than healthy patients. The pelvic obliquity range of motion was of 10.12° ± 3.03 and rotation was of 18.23° ± 9.17. The mean hip flexion was of 9.48° ± 3.40. Ground reaction forces showed reduced braking and propelling forces. Joint moments were reduced for flexion and adduction (0.42 Nm/kg ± 0.2 and 0.30 Nm/kg ± 0.11, respectively) but the abduction moment was increased (0.42 Nm/kg ± 0.18). Conclusions The present study showed that osteonecrosis of the femoral head presents compensatory gait mechanisms, with increased pelvic motion and decreased knee flexion to protect the hip joint. Decreased moments for hip flexion and adduction were also identified and muscle weakness for those groups may be correlated to the disease.

Resumo Objetivos Embora a osteonecrose da cabeça do fêmur seja uma lesão prevalente, seus efeitos sobre os parâmetros da marcha não foram minuciosamente estudados e não estão bem estabelecidos na literatura atual. O objetivo principal do presente estudo é descrever a marcha em pacientes com osteonecrose. Métodos Trata-se de um estudo transversal. Nove pacientes com diagnóstico de osteonecrose da cabeça do fêmur, sob acompanhamento regular em ambulatório, foram selecionados para o presente estudo e submetidos à análise da marcha com Vicon Motion Capture Systems. Os dados espaciais e temporais foram obtidos e os ângulos articulares foram calculados com o sistema de coordenadas angulares de Euler. Sistemas de coordenadas distais e plataformas de força foram utilizados para o cálculo de momentos articulares e de forças de reação ao solo, respectivamente. Resultados Os pacientes com osteonecrose apresentaram menor velocidade (0,54 m/s ± 0,19) e menor cadência (83,01 passos/minuto ± 13,23) do que pacientes saudáveis. As amplitudes de movimento de obliquidade e rotação pélvica foram de 10,12°± 3,03 e 18,23° ± 9,17, respectivamente. A média de flexão do quadril foi de 9,48° ± 3,40. O estudo das forças de reação ao solo revelou redução das forças de frenagem e propulsão. Os momentos articulares de flexão e adução caíram (0,42 Nm/kg ± 0,2 e 0,30 Nm/kg ± 0,11), mas o momento de abdução aumentou (0,42 Nm/kg ± 0,18). Conclusões O presente estudo mostrou que a osteonecrose da cabeça do fêmur é associada a mecanismos compensatórios da marcha, com aumento da movimentação pélvica e diminuição da flexão do joelho para proteção da articulação do quadril. A redução dos momentos de flexão e adução do quadril também foi identificada e a fraqueza destes grupos musculares pode estar correlacionada à doença.

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Kummel's disease is a crush fracture of a vertebral body caused by a minor trauma, with the most accepted etiology being avascular necrosis. It is more frequent in individuals with risk factors such as osteoporosis or prolonged treatment with corticosteroids. Initially, it usually has normal radiological tests and an asymptomatic period, followed by a progressive onset of pain along with probable kyphosis and a sign of void or fluid abscess on radiological tests, which may create nerve/spinal involvement. The case is presented of a 76-year-old man, who was admitted to this center for the differential diagnosis of a single vertebral lesion. After imaging tests and biopsy, the definitive diagnosis of Kummel's disease was reached. The confirmatory diagnosis was reached by vertebral biopsy, but given its invasive nature, imaging techniques can play a significant role. As regards metabolic imaging tests, bone scintigraphy has shown to be one of the most sensitive tools to detect ischemia in earlier stages or to determine if it affects other locations. The whole body scan with diphosphonates shows an increase in activity in relation to bone remodeling activity in this condition. The 3-phase study makes it possible to differentiate whether it is an acute/subacute or chronic process, and can influence the therapeutic decision. Knowledge of this disease is important to make a differential diagnosis with tumour or infectious pathology, with emphasis on performing imaging tests in the event of persistent pain with a normal initial plaque.

La enfermedad de Kummel es una fractura-aplastamiento de un cuerpo vertebral precedida por un traumatismo menor, cuya etiología más aceptada es la necrosis avascular. Es más frecuente en individuos con factores de riesgo como osteoporosis o tratamiento prolongado con corticoides. Inicialmente, suele presentar pruebas radiológicas normales y un periodo asintomático, con aparición progresiva del dolor junto a probable cifosis y signo del vacío o absceso líquido en las pruebas radiológicas, pudiendo llegar a crear compromiso nervioso/medular. Presentamos el caso de un varón de 76 arios que ingresa en nuestro centro para el diagnóstico diferencial de una lesión única vertebral; tras la realización de las pruebas de imagen y biopsia se llega al diagnóstico definitivo de enfermedad de Kummel. El diagnóstico de confirmación de esta enfermedad se alcanza mediante la biopsia vertebral, pero dada su naturaleza invasiva, las técnicas de imagen toman un papel relevante. En relación con las pruebas de imagen metabólicas, la gammagrafía ósea ha demostrado ser una de las herramientas más sensibles para detectar isquemia en fases más tempranas o para conocer si afecta a otras localizaciones. El rastreo corporal de cuerpo completo con difosfonatos muestra un aumento de actividad en relación con la actividad ósea remodelativa en este cuadro. El estudio de tres fases permite diferenciar si se trata de un proceso agudo/subagudo o crónico, lo que influye en la decisión terapéutica. Es importante el conocimiento de esta enfermedad para realizar diagnóstico diferencial con patología tumoral o infecciosa e insistir en la realización de pruebas de imagen ante la persistencia del dolor con una placa inicial normal.

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Abstract Objective The present study analyzed the incidence of epiphyseal avascular necrosis in patients with slipped capital femoral epiphysis (SCFE) treated using a modified Dunn technique. In addition, this study determined the correlation of other variables with this incidence and described treatment complications. Methods This is a retrospective study with 20 patients treated by the same surgical team from 2009 to 2019 and followed up for 2 to 12 years. The analysis included general features, time from presentation to surgical procedure, classification, and intraoperative blood perfusion of the epiphysis, as well as complications and their treatment. Results All cases were severe; 65% were acute on chronic, and 55% of the SCFEs were unstable. Our complication rate was 45%, with 5 cases of avascular necrosis, 2 cases of deep infection, 1 case of material failure, and 1 case of joint instability. The statistical analysis revealed that the risk of necrosis was higher when the surgery occurred after a long hospitalization time and there was no intraoperative epiphyseal perfusion. Four necrosis cases happened within the first 5 years, and 1 case in the last 5 years of the study. Conclusion Our study showed that necrosis was the most common complication. It also revealed that surgery delay and lack of intraoperative epiphysis perfusion potentially predispose to avascular necrosis. Although with no statistical significance, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw. The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible and performed by an experienced, trained, and qualified team.

Resumo Objetivo Analisar a incidência da necrose avascular da epífise no tratamento do escorregamento da epífise proximal do fêmur pela técnica de Dunn modificada, correlacionando-a com outras variáveis. Como objetivo secundário, descrevemos outras complicações encontradas. Métodos Estudo retrospectivo com 20 pacientes tratados entre 2009 e 2019, com seguimento de 2 a 12 anos, tratados pela mesma equipe cirúrgica. A análise incluiu características gerais, tempo entre apresentação e procedimento cirúrgico, classificação, presença de perfusão sanguínea intraoperatória da epífise, avaliação das complicações e seus respectivos tratamentos. Resultados Todos os casos eram graves, 65% crônicos agudizados e 55% dos escorregamentos eram instáveis. Nossa taxa de complicações foi de 45%, sendo 5 casos de necrose avascular, 2 de infecção profunda, uma falha do material e uma instabilidade articular. Pacientes operados com maior tempo após a internação e os sem perfusão intraoperatória da epífise tiveram maior risco de necrose na análise estatística. Considerando o tempo do estudo, tivemos 4 casos de necrose nos primeiros 5 anos e 1 caso nos últimos 5 anos. Conclusão Nosso estudo demonstrou que a necrose foi a complicação mais comum e que o atraso para a realização da cirurgia e a ausência de perfusão da epífise no intraoperatório podem predispor à necrose avascular. Embora não estatisticamente significante, a instabilidade coxofemoral foi observada na forma de apresentação crônica e a fixação cirúrgica com fios rosqueados se mostrou menos eficaz que a fixação com parafuso canulado. Este procedimento deve ser reservado para casos graves nos quais outras técnicas não sejam possíveis e realizado por equipe experiente, treinada e capacitada.

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PURPOSE: This study investigated the incidence of AVN in patients with cerebral palsy who underwent a hip reconstruction surgery (soft tissue release, femur and pelvic osteotomies) and its impact on quality of life. METHODS: Retrospective study, with clinical and radiographic analysis of 104 patients (128 hips) GMFCS IV and V with a minimum two year follow-up. Reimers migration percentage, the amount of abduction, acetabular index, and the neck-shaft angle were collected before and after surgery. Modified Tönnis classification was used to analyze the hips before surgery, and the Bucholz and Ogden classification was used to identify hips with AVN. Function and quality of life were investigated with the CPCHILD questionnaire after surgery. RESULTS: The mean age of participants at surgery was 120.1 months (72-184), and it was not related with AVN (p = 0.946). AVN signs were observed in 62 hips (48.5%). The mean pre-op Reimers value was 68.7% (16-100) in normal hips and 83.1% (0-100) in hips with AVN (p = 0.003). All hips considered as Tönnis IV before surgery developed AVN (p = 0.006). The amount of abduction did not differ between hips that developed AVN and those that did not (p = 0.313). Patients who developed AVN had lower scores of quality of life (p = 0.023) and comfort (p = 0.025) according to the CPCHILD questionnaire. CONCLUSION: We observed a relationship between the greater pre-operative severity according to the Reimers index and the modified Tonnis classification and the development of AVN.

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Femoral head necrosis (FHN) is one of the most common conditions in fast growing broilers, being characterized by separation of articular cartilage from epiphysis and classified as femoral head separation (FHS) or FHS with laceration (FHSL) depending on severity. Although molecular mechanisms involved with this disorder have been observed, its etiology is still unclear. Therefore, the expression of 15 candidate genes, chosen based on previous transcriptomic studies, was evaluated in the articular cartilage (AC) of normal and FHS-affected broilers at 21 days of age. Samples were collected based on the absence or presence of FHS for physical-chemical and qPCR analysis. The AvBD2, RHAG, COL28A1, ADA and ANGPTL7 were upregulated in FHS-affected broilers compared to the healthy group. These genes are involved in immune response, defense against pathogens, inflammation, cellular migration and adhesion, indicating different molecular mechanisms to control FHS progression at early age. Our results can contribute to improve the knowledge on FHN etiology in chickens and other species, such as horse and pigs that are severely affected by bone disorders.

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