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Long-Term Clinical Results After Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis

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Long-Term Clinical Results After Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/299549448 Long-term Clinical Results after Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis Article in Orthopedic Reviews · March 2016 DOI: 10.4081/or.2016.6150 CITATIONS READS 5 30 8 authors, including: Tim Classen Stefan Landgraeber University Hospital Essen University Hospital Essen 33 PUBLICATIONS 156 CITATIONS 58 PUBLICATIONS 515 CITATIONS SEE PROFILE SEE PROFILE Xinning Li Christoph Zilkens Boston University Universitätsklinikum Düsseldorf 104 PUBLICATIONS 867 CITATIONS 139 PUBLICATIONS 2,129 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: Patient-specific knee arthroplasty View project Local anaesthetics and opioids View project All content following this page was uploaded by Xinning Li on 01 April 2016. The user has requested enhancement of the downloaded file. Orthopedic Reviews 2016; volume 8:6150 Long-term clinical results after Introduction Correspondence: Tim Claßen, Department of iloprost treatment for bone Orthopedics, University of Duisburg-Essen, marrow edema and avascular Avascular osteonecrosis (AVN) is related to Hufelandstr. 55, D-45147 Essen, Germany. the interruption of blood supply or a disorder of Tel.: +49.201.4089.2138 - Fax: +49.201.723.5910. necrosis E-mail: [email protected] the circulation to the subchondral bone, which Tim Claßen,1 Antonia Becker,1 is a particularly vulnerable location due to the Key words: Avascular osteonecrosis; Iloprost; capillary terminal branches. The detailed Stefan Landgraeber,1 Marcel Haversath,1 bone marrow edema. pathogenesis of AVN and the relationship Xinning Li,2 Christoph Zilkens,3 between the underlying circulatory disorder is Contributions: the authors contributed equally. 3 1 Rüdiger Krauspe, Marcus Jäger often unclear.1 However, there are many theo- 1Department of Orthopedics, University ries on the cause of AVN and associated risk Conflict of interest: the authors declare no poten- tial conflict of interest. of Duisburg-Essen, Essen, Germany; factors. The most common risk factors are cor- 2 Department of Orthopedic Surgery, tisone therapy, alcohol and nicotine abuse, Received for publication: 17 August 2015. Boston University School of Medicine, fractures and coagulopathies involving the cir- Revision received: 12 February 2016. 1-5 Sports Medicine and Shoulder Surgery, culatory system. AVN can affect all joints in Accepted for publication: 12 February 2016. the body, however the highest incidence is Boston, MA, USA; 3Department of seen in the hip, followed by the knee joint, This work is licensed under a Creative Commons Orthopedics, Heinrich-Heine University, humerus, talus and metatarsals. Bone marrow Attribution NonCommercial 4.0 License (CC BY- Düsseldorf, German edema that is typically visible on magnetic res- NC 4.0). onance imaging is directly related to the ©Copyright T. Claßen et al., 2016 osseous perfusion disorder and also indicates y Licensee PAGEPress, Italy a potentially reversible initial stage of avascu- Orthopedic Reviews 2016;8:6150 Abstract lar osteonecrosis. However, the bone marrow doi:10.4081/or.2016.6150 edema may also occur as a transient clinical The treatments of avascular osteonecrosis condition not associated with AVN. Thus, it is (AVN) include both conservative and surgical unclear if the pathogenesis of AVN arises from methods which are dependent on the stage the bone marrow edema at the beginning of Vasoactive prostaglandin analogue iloprost and progression of the disease. The vasoac- the disease or the bone marrow edema is sec- (PGI2) have been used in several areas of tive-prostaglandin-analogue iloprost (PGI2) ondary to another pathological process that is medicine including in the therapy of severe has been utilized in several areas of medicine self-limited which can result in complete heal- peripheral vascular disease, diabetic angiopa- and recently has been used for the treatment ing 6 to 12 months after conservative medical thy, pulmonary hypertension and after organ 6-10 of AVN. A total of 108 patients with 136 therapy (bone marrow edema syndrome). transplantation.15-19 In the recent years Iloprost osteonecrosis of different joints, etiology and The treatment of avascular osteonecrosis is has also been used in the therapy of early stage severity were treated with iloprost. The mean based on the clinical symptoms, stage of necro- avascular osteonecrosis and bone marrow follow-up was 49.71 months: range 15-96 sis and the size of the affected area. To evalu- edema with promising short-term results.20-26 months, and outcome measurements recorded ate the evolution of AVN, both the Ficat and the In this study, we evaluated 108 patients with a regarding subjective complaints, visual analog Association for Research on Osseous total of 136 avascular osteonecrosis in differ- Circulation (ARCO) is the mostly commonly scale (pain), function and survival. The out- ent joint locations and ARCO stages that have used classification by clinicians.11-13 Ficat come scores used include the Harris Hip been managed with medical Iloprost therapy introduced the original classification of AVN Score, Knee Society score, Foot and Ankle during the period of 2003 to 2010. The aim of based on radiographic findings. However, Survey, visual analogue scale (VAS) and a sep- the present study was to investigate the mid to there is greater difference in the intra and arate questionnaire. The location and etiology long-term results of Iloprost therapy in treat- interobserver reliability associated with the of AVN in our study demonstrated the typical ment of bone marrow edema or avascular Ficat system. Furthermore, it does not take pattern. All of the observed side effects of the osteonecrosis. Furthermore, the clinical and into account the size and location of the therapy were minor and completely reversible. radiographic results were stratified based on Non commercialnecrotic area into account. Thus, ARCO use devel- only the location of involvement, severity of clinical Most of patients (74.8%) showed a significant oped a classification taking into account of the improvement of subjective complaints and size and location of the lesion using both radi- presentation and patient risk factors. Our decrease in VAS pain scores after the treat- ographs and MRI to further stage AVN. In the hypothesis is that the clinical success of ment with iloprost. However, 20% of the treat- ARCO classification, there are four stages Iloprost is correlated to the severity of AVN that ed joints with the stadium Association for based on the findings of both radiographs and is based on the ARCO classification. Research on Osseous Circulation (ARCO) MRI. Surgical intervention during the advance grade 2, 71% with ARCO 3 and 100% with stages of AVN including core decompression, ARCO 4 underwent subsequent total joint osteotomy, and hip replacement is indicated replacement. The medical treatment of bone when there are radiographic signs of Materials and Methods marrow edema or avascular osteonecrosis by osteonecrosis such as osteopenia, sclerosis, Iloprost provides an safe and effective alterna- osteolytic or cystic lesions, joint space narrow- This study was approved by the Ethics tive strategy in the management of AVN pre- ing or flattening of the femoral head detectable Committee of the Medical Faculty of the senting in the early stages (ARCO 1 or 2). For in the conventional radiographs. Non surgical Heinrich-Heine, University of Dusseldorf more advanced stages (ARCO 3 or 4), surgical management of patients with AVN can be suc- Medical School (ethics number: 2355). A total intervention should be prioritized. cessful only in the early ARCO stages which is of 156 patients with painful bone marrow typically seen in patients that present with edema or AVN were recruited for this study and bone marrow edema.10,14 treated with Iloprost between the years of 2003 [Orthopedic Reviews 2016; 8:6150] [page 23] Article to 2010 in the orthopedic clinic of the until initiation of therapy with Iloprost was etiology of AVN, majority of the patients in our Heinrich-Heine, University Dusseldorf. documented as well as side effects of Iloprost. study (32.4%) had steroid induced AVN, 25.9% Patients excluded from this study that were no To document the patient satisfaction with the were idiopathic osteonecrosis, 18.5% of the longer available (n=34), expired (n=4) or therapy, the patients were asked the question osteonecrosis arise after a trauma, 16.7% were chose not to participate in the study for per- whether they would proceed with the Iloprost secondary to nicotine abuse and 7.4% were sonal reasons (n=10). Thus a total of 108 therapy for an additional cycle. For objective related to alcohol abuse (Figure 1). In addi- patients (69.2% or 108 out of 156) presenting assessment of therapeutic success, various tion, 25.9% of the patients with AVN were due with 136 painful bone marrow edema or radi- established clinical outcome scores were col- to multifactorial risk factors. Majority of the ographic evidence of avascular osteonecrosis lected. Depending on the involved joint, the AVN presented in the femoral head (52%), fol- were included in our study and followed up ret- Harris hip score (HHS), the Knee Society lowed by ankle (20%) and knee (18%). In 8% of rospectively. These included 48 women and 60 score (KSS) or the Foot and Ankle Survey cases, the osteonecrosis was located in the men with a mean age of 47.7 years (11-92 (FOAS) were used in our study. In addition, the foot. The duration of symptoms due to the AVN years) at the time of Iloprost treatment (Table range of motion of the corresponding joints before the Iloprost therapy was on average 13.6 1). All patients included in the study presented was also measured with a goniometer and months, although within the periods of one with bone marrow edema and symptomatic recorded in clinic. Pain intensity was recorded month to ten years, a large scatter of data was complaint of symptoms (pain) for more than 6 by the means of visual pain scale (VAS).
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