RESUMEN
PURPOSE: Post-traumatic osteonecrosis of the humeral head has a risk of progression to collapse in absence of treatment. The purpose of this study was to evaluate the results of mesenchymal stem cell grafting of the pre-collapse humeral head (study group) in adult patients with osteonecrosis and to compare the results with a simple core decompression without cells (control group). Patients After inclusion and randomization of 50 patients, 26 patients were enrolled in a single-blinded study for the cell therapy group. Twenty-four other patients were treated with simple core decompression without cells (control group). MATERIAL AND METHODS: After a mean of 12-year (range 10 to 15) follow-up, X-ray and MRI were used to evaluate the radiological results, while the Constant score and the visual analog scale were chosen to assess the clinical results. The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow concentration. The average total number of MSCs (counted as the number of colony-forming units-fibroblast) injected in each humeral head was a total injection of average 180,000 ± 35,000 cells (range 74,000 to 460,000). RESULTS: Both the treatment and control groups had a significantly improved clinical score (p < 0.01). At the last follow-up, pain on the visual analog scale and Constant score in the study group had significant improvement (respectively p < 0.001 and p < 0.01) as compared to the control group. Collapse was observed more frequently in the control group (87.5% versus 11.5% for cell therapy, p < 0.0001). The survival rates based on the requirement for further shoulder surgery (arthroplasty) as an endpoint were higher in the cell therapy group in comparison to those in the control group (92% versus 25%; p < 0.0001). CONCLUSION: Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.
Asunto(s)
Trasplante de Células Madre Mesenquimatosas , Células Madre Mesenquimatosas , Osteonecrosis , Estudios de Seguimiento , Humanos , Osteonecrosis/diagnóstico por imagen , Osteonecrosis/etiología , Osteonecrosis/cirugía , Estudios Prospectivos , Hombro , Resultado del TratamientoRESUMEN
PURPOSE: This study compared the clinical and radiological results of bone marrow mesenchymal stem cell implantation with traditional simple core decompression (CD) using a matched pair case-control design for osteonecrosis of the humeral head (ONHH) after fracture of the proximal humerus. PATIENTS: We retrospectively reviewed 64 patients who had surgery for ONHH. Thirty patients had been treated with cell therapy between 2010 and October 2015, with 18 patients at pre-collapse stage (8 stages-I, 10 stages-II), and 12 patients at post-collapse stages (7 stages-III and 5 stages-IV). Using a matched pair case-control design, these 30 study patients were compared to 34 other patients who were treated with simple core decompression (CD) without cells (control group). METHODS: The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow (BM) concentration. During a mean follow-up duration of 7years (5 to 10years), radiographs performed each year were used to evaluate the radiological results; the Constant score and visual analogue scale were chosen to assess the clinical results. We assessed stage progression, collapse and arthroplasty conversion rate. Survivor rate analysis was performed using these parameters as the primary endpoints. RESULTS: Among the 30 shoulders included in the cell therapy group, three (10%) humeral heads had collapsed at the most recent follow-up, versus 25 (74%) in 34 shoulders after simple core decompression (P<0.0001). As consequence, we observed statistically significant difference (P=0.0001) in the humeral head survival (absence of arthroplasty conversion) rate at the end time point between the cell therapy group (93% survival) and simple core decompression (26% survival). Better results were obtained for early stages (stages I and II) osteonecrosis without collapse at baseline. CONCLUSION: Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.
Asunto(s)
Osteonecrosis , Hombro , Tratamiento Basado en Trasplante de Células y Tejidos , Humanos , Osteonecrosis/terapia , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The humeral head is the second most common site for nontraumatic osteonecrosis after the femoral head, yet it has attracted relatively little attention. Osteonecrosis is associated with many conditions, such as traumatism, corticosteroid use, sickle cell disease, alcoholism, dysbarism (or caisson disease), and Gaucher's disease. The diagnosis is clinical and radiographic with MRI, with radiographs being the basis for staging. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis, but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of fractures, steroid usage, or sickle cell disease, and in divers. This report reviews osteonecrosis of the humeral head, with an emphasis on causes, clinical evaluation, imaging, and classification.
Asunto(s)
Osteonecrosis , Articulación del Hombro , Humanos , Osteonecrosis/clasificación , Osteonecrosis/diagnóstico por imagen , Osteonecrosis/etiología , Factores de Riesgo , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugíaRESUMEN
PURPOSE: No study has reported the risk of other site osteonecroses after the diagnosis of multifocal osteonecrosis related to corticosteroids in patients who continue this corticosteroid treatment. An analysis of the time-course to other sites of osteonecrosis, as well as the effects of underlying corticosteroid risk factor on the evolution of asymptomatic lesions at the time of diagnosis, is presented. METHODS: Two hundred patients were followed prospectively every year during a minimum ten years with a radiograph if a joint became symptomatic. In absence of evidence of osteonecrosis on radiographs of a symptomatic or non-symptomatic joint (hips, shoulders, knees, ankles), patients had an MRI performed at the most recent follow up. The average duration of follow-up after inclusion of the patient in the study was 15 years (range 10-20). RESULTS: Of the 200 patients followed for an average of 15 years (minimum 10 years, maximum 20 years), 35 patients developed new osteonecrosis lesions during the period of study. Asymptomatic lesions became symptomatic and a high number of collapse was observed resulting in 258 arthroplasties (187 hips, 51 shoulders, 20 knees) at the most recent follow up. CONCLUSION: The continuation of peak doses (>200 mg) of corticosteroids predicted (p = 0.04) occurrence of new lesions and the continuation of corticosteroids without peak dose was a risk for quicker progression to collapse.