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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Shah KN, Racine J, Jones LC, Aaron RK. Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med 2015;8:201-9. Review/Other-Tx N/A To review the structural consequences of bone ischemia and suggests a common pathway via compromised circulation leading to ischemia and consequent marrow and osteocyte necrosis. No results stated in abstract. 4
2. Heinen AK, Harris TG. Avascular Necrosis of the Tibial Plafond Following Rotational Ankle Fractures. [Review]. Foot Ankle Clin. 24(1):113-119, 2019 Mar. Review/Other-Dx N/A To describe diagnosis and treatment options of patients at high risk for developing avascular necrosis (AVN) following rotational ankle fractures. No results stated in abstract. 4
3. Hernigou P, Hernigou J, Scarlat M. Shoulder Osteonecrosis: Pathogenesis, Causes, Clinical Evaluation, Imaging, and Classification. [Review]. Orthopaedic Audio-Synopsis Continuing Medical Education [Sound Recording]. 12(5):1340-1349, 2020 Oct. Review/Other-Dx N/A To review osteonecrosis of the humeral head, with an emphasis on causes, clinical evaluation, imaging, and classification. No results stated in abstract. 4
4. Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am 2015;97:1604-27. Review/Other-Tx N/A To review the results of hemiresurfacing and total resurfacing arthroplasty. No results stated in abstract. 4
5. Murphey MD, Foreman KL, Klassen-Fischer MK, Fox MG, Chung EM, Kransdorf MJ. From the radiologic pathology archives imaging of osteonecrosis: radiologic-pathologic correlation. Radiographics. 2014;34(4):1003-1028. Review/Other-Dx N/A To review the underlying pathology of osteonecrosis. No results stated in abstract. 4
6. Barille MF, Wu JS, McMahon CJ. Femoral head avascular necrosis: a frequently missed incidental finding on multidetector CT. Clin Radiol. 69(3):280-5, 2014 Mar. Observational-Dx 144 hips in 72 patients To determine the incidence of missed femoral head avascular necrosis (AVN) on pelvic computed tomography (CT) performed for clinical indications other than assessment for AVN. The study readers diagnosed 35/43 (81%) MRI-proven AVN cases in 22/28 (79%) patients. Four of the 35 (11%) cases of MRI-proven, CT-visible AVN were prospectively reported in 3/22 (14%) patients at initial clinical interpretation, with a miss rate of 89% per hip and 86% per patient. 2
7. Rolston VS, Patel AV, Learch TJ, et al. Prevalence and Associations of Avascular Necrosis of the Hip in a Large Well-characterized Cohort of Patients With Inflammatory Bowel Disease. J. clin. rheumatol.. 25(1):45-49, 2019 Jan. Observational-Dx 27 patients To determine the prevalence of AVN in our IBD population and to evaluate these subjects for the presence of clinical characteristics associated with AVN on computed tomography (CT) imaging. We found that 59% of the concurrent radiology reports did not comment on the presence of AVN, suggesting that incidental CT findings of AVN among IBD patients is likely under-reported. Notably, we found that 63% of these cases had documented complaints of low back and/or hip pain. Using logistic regression, we found an association between ANCA positive status across IBD (p=0.007) and a smoking history in CD (p=0.03) with the presence of AVN. 4
8. Cohen-Rosenblum A, Cui Q. Osteonecrosis of the Femoral Head. [Review]. Orthop Clin North Am. 50(2):139-149, 2019 Apr. Review/Other-Dx N/A To describe the management of  Osteonecrosis of the Femoral Head. No results stated in abstract. 4
9. Hernigou P, Flouzat-Lachaniette CH, Daltro G, Galacteros F. Talar Osteonecrosis Related to Adult Sickle Cell Disease: Natural Evolution from Early to Late Stages. J Bone Joint Surg Am. 98(13):1113-21, 2016 Jul 06. Review/Other-Dx 45 patients The purpose of our study was to define the natural progression of asymptomatic and symptomatic talar osteonecrosis from its early stages in patients with sickle cell disease. The osteonecrosis was unilateral in 15 patients and bilateral in 30 at the time of the initial examination. Forty-five ankles were asymptomatic and 30 were symptomatic at the initial evaluation. MRI performed at the time of the most recent follow-up, and compared with MRI performed at diagnosis, did not show partial or total regression of the osteonecrosis in any of the patients, even those with asymptomatic stage-I osteonecrosis. At the time of the most recent follow-up (mean, 20 years; range, 15 to 25 years), pain and collapse had developed in all except 12 ankles. 4
10. Niinimaki R, Suo-Palosaari M, Pokka T, Harila-Saari A, Niinimaki T. The radiological and clinical follow-up of osteonecrosis in cancer patients. Acta Oncol. 58(4):505-511, 2019 Apr. Observational-Dx 233 ON lesions in 54 patients To explore the natural course of ON in patients treated for cancer by using radiological classification suitable for multisite ON lesions and to assess correlations between the ON grade and surgical procedures. A total of 14 different ON sites were detected; the hip was the most common site (n = 51), followed by the femur (n = 45), tibia (n = 41) and knee (n = 37). Among the 233 ON lesions, 78.1% did not require surgical procedures. The remaining lesions required total joint arthroplasty (TJA; 40/233, 17.2%), core decompression (3.4%) and arthroscopy (1.3%). Most TJAs (33/40, 82.5%) were performed on the hip. ONs of the knee required TJAs only once; grade 3 knee ONs frequently healed (58%, 11/19). 4
11. Issa K, Naziri Q, Kapadia BH, Lamm BM, Jones LC, Mont MA. Clinical characteristics of early-stage osteonecrosis of the ankle and treatment outcomes. J Bone Joint Surg Am. 96(9):e73, 2014 May 07. Observational-Tx 73 patients, 101 ankles To describe the clinical manifestations of osteonecrosis involving the distal tibia and talus, to identify risk factors associated with the disease, and to evaluate the efficacy of percutaneous drilling for the treatment of ankles with early-stage symptomatic osteonecrosis. Eighty-five ankles had isolated talus osteonecrosis, eleven ankles had involvement of the distal tibia and talus, and five ankles had isolated distal tibial disease. Twenty-nine patients (40%) had initially presented with symptomatic osteonecrosis of another joint, most commonly the knee (37%), the hip (29%), and the shoulder (25%). The most common identifiable risk factors included chronic corticosteroid use (49.3%), alcohol abuse (35.6%), tobacco use (29%), and hypertension (20.5%). Overall, 83% of ankles did not demonstrate further disease progression after the procedure. There were significant improvements (p < 0.05) in clinical and patient-reported outcomes after surgical treatment. 2
12. Nawata K, Nakamura J, Hagiwara S, et al. Predictive value of magnetic resonance imaging for multifocal osteonecrosis screening associated with glucocorticoid therapy. Modern Rheumatology. 30(3):586-591, 2020 May. Review/Other-Dx 107 patients To elucidate the distribution of multifocal osteonecrosis associated with glucocorticoid therapy using magnetic resonance imaging (MRI) and to establish a MRI screening method. Osteonecrosis was observed in hip (68%), knee (44%), ankle (17%) and shoulder (15%) joints. Patients with bilateral osteonecrosis in their hips were likely to have bilateral osteonecrosis in their knees, whereas patients without osteonecrosis in both hips were unlikely to have osteonecrosis in both knees (p = .0299). 4
13. Nam KW, Kim YL, Yoo JJ, Koo KH, Yoon KS, Kim HJ. Fate of untreated asymptomatic osteonecrosis of the femoral head. J Bone Joint Surg Am. 2008;90(3):477-484. Review/Other-Dx 105 hips To evaluate the fate of untreated asymptomatic ONFH with an emphasis on the size of the lesion. 62 hips became symptomatic, and 43 hips remained asymptomatic for more than 5 years (average, 8 years and 7 months). Of the 21 hips with a small necrotic lesion (<30% of the area of the femoral head), 1 became painful; of the 24 hips with a medium-sized necrotic lesion (30% to 50% of the area of the femoral head), 11 became painful; and of the 60 hips with a large necrotic lesion (>50% of the area of the femoral head), 50 became painful. 46/62 hips that became symptomatic required surgery. Pain developed within 5 years after the diagnosis in 58 (94%) of the 62 symptomatic hips. 4
14. Sakai T, Sugano N, Nishii T, Hananouchi T, Yoshikawa H. Extent of osteonecrosis on MRI predicts humeral head collapse. Clin Orthop Relat Res 2008;466:1074-80. Observational-Dx 27 patients and 46 humeral heads To determine whether prognosis was related to the extent and location of necrotic lesions on MRI. Of the 46 lesions, 34 were less than 90(degree) and did not collapse, whereas 11 of the other 12 lesions of more than 90(degree) (92%) collapsed within 4 years. Of these 11 collapsed lesions, four of less than 100(degree) did not progress, followed by reparative reaction on plain radiographs, whereas the other seven of more than 100(degree) progressed to osteoarthritis. 3
15. Mont MA, Marulanda GA, Jones LC, et al. Systematic analysis of classification systems for osteonecrosis of the femoral head. J Bone Joint Surg Am 2006;88 Suppl 3:16-26. Review/Other-Dx 157 reports To delineate the classification systems utilized in reports published since 1985 and, through a comparison of the most commonly used systems, to identify consistent factors that would allow for cross-publication comparisons to be made. Sixteen major classification systems that made use of more than one radiographic factor were identified, and nine of these systems had one to five modifications reported throughout the literature. Additionally, eleven other systems made use of single factors obtained from either magnetic resonance imaging or anatomic data. The review revealed that four classification systems accounted for greater than 85.4% of the reported studies. 4
16. Ajmal M, Matas AJ, Kuskowski M, Cheng EY. Does statin usage reduce the risk of corticosteroid-related osteonecrosis in renal transplant population? The Orthopedic clinics of North America 2009;40:235-9. Observational-Tx 2881 patients To determine if statin usage, in renal transplantation patients, is associated with a reduction in incidence of osteonecrosis. In the overall patient cohort of 2881 patients, 195 (7%) developed ON in 286 joints. In the femoral head, 96 patients developed ON unilaterally and 91 bilaterally. Eight patients had involvement of other bones. Among the 338 patients in the statin cohort, 15 patients (4.4%) developed ON at 23 sites (all involving the femoral head). In the non-statin cohort of 2543 patients, 180 patients (7%) developed ON at 263 sites (255 femoral heads and eight other sites). ON-free survival stratified by statin usage did not show a relationship between statin exposure and development of ON (p = 0.14, log-rank) (Fig 1). At 5 years, the ON-free survivorship for those patients on statins versus not on statins was 96% ± 2.1% (95% confidence interval) versus 94% ± 1.0% (95% C.I.). Cox regression revealed that statin usage did not predict (p = 0.8) ON-free survival. Other variables (Table 2) that were associated with a higher incidence of ON were (1) male gender (p = 0.008), (2) higher number of rejection episodes (p = 0.009), and (3) earlier year of transplant (p = 0.01). 2
17. Cao F, Liu G, Wang W, et al. Combined Treatment with an Anticoagulant and a Vasodilator Prevents Steroid-Associated Osteonecrosis of Rabbit Femoral Heads by Improving Hypercoagulability. Biomed Res Int 2017;2017:1624074. Review/Other-Tx 30 rabbits To investigate the effects of combination prevention with enoxaparin and EGb 761 on steroid-associated ONFH in rabbits. No results stated in abstract. 4
18. Yuan HF, Guo CA, Yan ZQ. The use of bisphosphonate in the treatment of osteonecrosis of the femoral head: a meta-analysis of randomized control trials. Osteoporos Int 2016;27:295-9. Meta-analysis 5 trials involving 329 subjects To determine if bisphosphonates provide a better clinical outcome in the treatment of osteonecrosis of the femoral head (ONFH) when compared with placebo. The clinical outcomes of patients with ONFH was not significantly improved by bisphosphonate therapy (progression to collapse: risk ratio = 0.71 (0.41, 1.24), p = 0.23; THA incidence: risk ratio = 0.61 (0.33, 1.15), p = 0.13; HHS improvement: mean difference = 3.26 (-5.12, 11.64), p = 0.45). The I (2) statistic showed the existence of considerable heterogeneity (all I (2) = 50 %), which was explained by one trial where bisphosphonate alone was used with no additional therapy. However, when this trial was excluded, the clinical outcomes after bisphosphonate therapy were still not significantly improved compared with placebo. Not Assessed
19. Banerjee S, Issa K, Pivec R, Kapadia BH, Khanuja HS, Mont MA. Osteonecrosis of the hip: treatment options and outcomes. The Orthopedic clinics of North America 2013;44:463-76. Review/Other-Dx N/A To provide the orthopedic community with the latest evidence regarding the suitability of currently available treatment modalities in various stages of the disease. No results stated in abstract. 4
20. Hernandez A, Nunez JH, Sallent A, Gargallo-Margarit A, Gallardo-Calero I, Barro V. Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip. Clin. orthop. surg.. 12(2):151-157, 2020 Jun. Observational-Tx 18 hips To determinate if the core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate could be used to prevent radiographic progression of early stage osteonecrosis of the hip. The mean follow-up was 68.9 months (SD, 15.0 months). In most cases (70.6%), the etiology of the osteonecrosis of the femoral head was corticosteroid use; in the remaining cases, secondary to alcohol use. Core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate did not prevent progression to collapse (< 80% at 5 years) although modified Harris hip scores improved. Overall median survival with the total hip arthroplasty as endpoint was 23 months (95% confidence interval [CI], 14.9 to 31.1 months). Overall median survival time with any degree of collapse as endpoint was 7 months (95% CI, 2.0 to 12.0 months). 2
21. Larson E, Jones LC, Goodman SB, Koo KH, Cui Q. Early-stage osteonecrosis of the femoral head: where are we and where are we going in year 2018? Int Orthop 2018;42:1723-28. Review/Other-Dx N/A To review the management of patients with osteonecrosis of the femoral head. No results stated in abstract. 4
22. Pierce TP, Jauregui JJ, Elmallah RK, Lavernia CJ, Mont MA, Nace J. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med 2015;8:228-32. Review/Other-Tx N/A The purpose of this review is to describe the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling, and (4) the overall outcomes of this procedures. No results stated in abstract. 4
23. Kim SJ, Kang DG, Park SB, Kim JH. Is Hemiresurfacing Arthroplasty for Osteonecrosis of the Hip a Viable Solution? The Journal of arthroplasty 2015;30:987-92. Meta-analysis 430 patients from 14 published studies were identified. To evaluate the outcomes of hemiresurfacing arthroplasty (HRA) in patients with osteonecrosis (ON). Overall clinical success rate was 74%. A total of 102 (21%) revision surgeries were required after the index procedure. Inadequate
24. Zalavras CG, Lieberman JR. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg 2014;22:455-64. Review/Other-Dx N/A To review the diagnostic, medical and surgical management of patients with osteonecrosis of the femoral head. No results stated. 4
25. Rubin DA, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria® Chronic Wrist Pain. J Am Coll Radiol 2018;15:S39-S55. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chronic wrist pain. No results stated in abstract. 4
26. Tafur M, Bencardino JT, Roberts CC, et al. ACR Appropriateness Criteria® Chronic Foot Pain. J Am Coll Radiol 2020;17:S391-S402. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for No results stated in abstract. 4
27. Cheng W, Xian H, Wang L, et al. Frog leg lateral view is a reliable predictor of the prognosis in osteonecrosis of the femoral head. J Orthop Res 2020. Observational-Dx 90 hips in 76 patients with ONFH To investigate whether the location of the necrotic area in the frog leg lateral (FL) view would affect the prediction of prognosis for patients with ONFH. All patients underwent personalized hip physiotherapy, and the cumulative survival rate with subsequent collapse and/or requirement for further hip surgery as the endpoints was evaluated for the two classification systems. The percentage of the necrotic area was found to be significantly greater in the FL views (47.0 ± 1.5%) than that in the AP views (37.7 ± 1.7%, P < .01). Intraobserver reliability in the JIC classification (mean: 0.91, range: 0.85-0.98) was higher than that in the FL view type (mean: 0.77, range: 0.63-0.89; P < .01), as well as the interobserver reliability in the JIC classification (mean: 0.74, range: 0.38-0.87) was higher than that in the FL view type (mean: 0.58, range: 0.31-0.76; P < .01). 2
28. Choi HR, Steinberg ME, E YC. Osteonecrosis of the femoral head: diagnosis and classification systems. Curr Rev Musculoskelet Med 2015;8:210-20. Review/Other-Dx N/A To address the diagnosis and staging system of ON. No results stated in abstract. 4
29. Beltran J, Herman LJ, Burk JM, et al. Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation. Radiology 1988;166:215-20. Observational-Dx 49 patients (85 hips) To determine the correlation of femoral avascular necrosis with MRI, scintigraphy and biopsy. Five hips had negative MR images, positive findings at bone marrow biopsy, positive bone pressure measurement (BMP), and positive bone scans. A comparison between MR images and bone scans showed MR imaging to be superior, with a sensitivity of 88.8% (vs. 77.5%) and a specificity of 100% (vs. 75%). BMP was the most sensitive (92%) but least specific test (57%). 3
30. Ryu JS, Kim JS, Moon DH, et al. Bone SPECT is more sensitive than MRI in the detection of early osteonecrosis of the femoral head after renal transplantation. J Nucl Med. 2002;43(8):1006-1011. Observational-Dx 24 patients To compare the diagnostic sensitivity of Tc99m-MDP bone SPECT and MRI in the early detection of femoral head osteonecrosis after renal transplantation. A total of 32 femoral heads, including 24/29 painful hips and 8/19 asymptomatic contralateral hips, were confirmed as having osteonecrosis. SPECT detected osteonecrosis in all 32 of the femoral heads, resulting in a sensitivity of 100% (32/32), whereas MRI detected osteonecrosis in 21 femoral heads, for a sensitivity of 66% (21/32, P<0.005). SPECT showed the type 1 pattern in 13 and the type 2 in 19. 10/13 femoral heads with the type 1 pattern were false-negative on MRI, whereas only 1 of 19 with the type 2 pattern was normal on MRI (P<0.001). There were 6 femoral heads with normal MRI findings and abnormal SPECT findings (type 1 pattern) in 3 patients, for whom hip pain decreased and radiographic findings were normal during follow-up. Follow-up bone SPECT showed a decreasing area of cold defect in 4 femoral heads. 1
31. Dasa V, Adbel-Nabi H, Anders MJ, Mihalko WM. F-18 fluoride positron emission tomography of the hip for osteonecrosis. Clin Orthop Relat Res 2008;466:1081-6. Observational-Dx Eleven patients (17 hips) To evaluate F-18 fluoride positron emission tomography (PET) imaging modality for use in detection of the bone involved in ON of the hip. Nine of 17 hips (8 patients) had acetabular increased uptake when using the F-18 fluoride PET scans that were not seen on MRI, single photon emission computed tomography, or bone scans. When the PET and MRI scans for right-sided ON of the femoral head were compared, an agreement of 88.9% (95% CI = 51.8 to 99.7) was determined. PET versus MRI for the left side of the femoral head revealed an agreement of 87.5% (95% CI = 47.4 to 99.7). 3
32. Kim JW, Ryu JS, Baek S, Byun SE, Chang JS. The timing of bone SPECT to predict osteonecrosis after internal fixation of femur neck fractures. J Orthop Sci 2017;22:457-62. Observational-Dx 44 patients To investigate whether osteonecrosis of the femoral head (OFH) after internal fixation of femoral neck fracture could be predicted by early and late bone SPECT. OFH developed in 9 out of 44 patients but no patient showed nonunion. Seventeen patients with normal femoral head uptake on early bone SPECT were healed. Of 27 patients with decreased femoral head uptake on early bone SPECT, 2 patients developed OFH on radiography before 3 months postoperatively, 18 patients recovered to normal uptake on the late SPECT, and the remaining 7 patients still showed decreased uptake on the late SPECT at 3 months postoperatively. All of these 7 cases finally developed OFH on radiography. 3
33. Yoon JY, Lee SJ, Yoon KS, Yoon PW. The diagnostic value of SPECT/CT in predicting the occurrence of osteonecrosis following femoral neck fracture: a prospective cohort study. BMC Musculoskeletal Disorders. 21(1):517, 2020 Aug 03. Observational-Dx 30 patients To evaluate the diagnostic value of SPECT/CT for the occurrence of ONFH by quantifying the perfusion status of the femoral head. When the population was divided into intact and defective perfusion groups on scintigraphy, the sensitivity, specificity, and accuracy of the test were 83.3, 75.0, and 76.7%, respectively. The mean head-to-head uptake ratio value with a 95% confidence interval (CI) was 1.10 (95% CI: 0.85-1.36). In the osteonecrosis group, the mean value of the head-to-head uptake ratio was 0.33 (95% CI: 0.28-0.38). In contrast, the ratio was 1.30 (95% CI: 1.03-1.57) in the non-osteonecrosis group, demonstrating a significant difference in the uptake ratio (P < 0.001). When the cutoff value of the uptake ratio was set to 0.5, both the sensitivity and specificity were 100%. There was also a significant difference in the head-to-acetabulum uptake ratio between the two groups (P < 0.001). 2
34. An YS, Park S, Jung JY, Suh CH, Kim HA. Clinical characteristics and role of whole-body bone scan in multifocal osteonecrosis. BMC Musculoskelet Disord. 20(1):23, 2019 Jan 15. Observational-Dx 30 patients To evaluate the diagnostic value of SPECT/CT for the occurrence of ONFH by quantifying the perfusion status of the femoral head. Twenty-four patients out of 30 achieved bone union, whereas the others developed ONFH. When the population was divided into intact and defective perfusion groups on scintigraphy, the sensitivity, specificity, and accuracy of the test were 83.3, 75.0, and 76.7%, respectively. The mean head-to-head uptake ratio value with a 95% confidence interval (CI) was 1.10 (95% CI: 0.85-1.36). In the osteonecrosis group, the mean value of the head-to-head uptake ratio was 0.33 (95% CI: 0.28-0.38). In contrast, the ratio was 1.30 (95% CI: 1.03-1.57) in the non-osteonecrosis group, demonstrating a significant difference in the uptake ratio (P < 0.001). When the cutoff value of the uptake ratio was set to 0.5, both the sensitivity and specificity were 100%. There was also a significant difference in the head-to-acetabulum uptake ratio between the two groups (P < 0.001). 2
35. Cajiao K, Setoain FJ, Peris P. Multifocal Osteonecrosis: The Usefulness of Bone Scintigraphy. J Clin Rheumatol 2020:[E-pub ahead of print]. Review/Other-Dx 1 To review a case with multifocal osteonecrosis Magnetic resonance imaging (MRI) of the right knee revealed extensive bilateral bone infarcts in the metaphysis and epiphysis of the femur and tibia, which were asymptomatic at this time. Bone scintigraphy was performed, showing increased radionuclide uptake of the proximal and distal femurs, tibias, and humerus, indicative of a multifocal osteonecrosis, as demonstrated in the radiologic study (Fig.). Further workup, including an extensive thrombophilic profile was negative. 4
36. Hauzeur JP, Pasteels JL, Schoutens A, et al. The diagnostic value of magnetic resonance imaging in non-traumatic osteonecrosis of the femoral head. J Bone Joint Surg Am. 1989;71(5):641-649. Review/Other-Dx 25 patients To assess the effectiveness of nuclear MRI in the detection of ONFH. Of the 49 hips, 33 had histological proof of osteonecrosis. 22 (67%) of these hips showed definite necrosis on the plain radiographs; 18 (62%), on the 29 available CT scans; 24 (77%), on the 31 available radionuclide bone scans; and all of the hips, on the MRI studies. In 6 additional hips, there were histological changes (marrow necrosis, edema, hemorrhage, and fibrosis) in the medullary spaces without detectable osteonecrosis. The plain radiographs and CT scans of these 6 hips were normal except for the CT scan of 1, and the radionuclide uptake on bone-scanning was abnormal in 4 of the 6, as were the MRI studies. In the 2 hips that had normal MRI studies, the biopsies showed only destruction of fat cells in the medullary spaces, with no edema or fibroblastic reaction. 4
37. Stevens K, Tao C, Lee SU, et al. Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol. 2003;180(2):363-368. Observational-Dx 45 patients To compare the sensitivity of unenhanced radiography, CT, and MRI in revealing subchondral fractures. At 6 months, 18 fractures were shown on CT scans, but only 12 were detected on radiographs, and 6 on MRIs. At 12 months, 20 subchondral fractures were detected on CT scans, but only 17 were seen on radiographs and 11, on MRIs. Compared with CT, MRI has a sensitivity and specificity of 38% and 100%, and unenhanced radiography has a sensitivity and specificity of 71% and 97%, respectively. On T2-weighted MRIs, the subchondral fractures were visualized as crescentic high-signal-intensity lines, and in all patients, on the corresponding CT scans, the fracture clearly breached the femoral cortex. 2
38. Yeh LR, Chen CK, Huang YL, Pan HB, Yang CF. Diagnostic performance of MR imaging in the assessment of subchondral fractures in avascular necrosis of the femoral head. Skeletal Radiol. 2009;38(6):559-564. Observational-Dx 25 patients To determine the accuracy of routine MRI in correctly identifying subchondral fracture in AVN of the femoral head without apparent focal collapse on standard radiographs. When the diagnoses of the 2 readers were compared with each other, only 16/28 diagnoses (57.5%) agreed. 17 of the 28 MRI readings (60.7%) made by the musculoskeletal radiologist and 15/28 (53.5%) made by the general radiologist agreed with those of the CT standard. False-positive diagnosis (that is, diagnosis of fracture when no fracture could be seen on CT) was more common than false-negative diagnosis. 2
39. Chan WP, Liu YJ, Huang GS, et al. Relationship of idiopathic osteonecrosis of the femoral head to perfusion changes in the proximal femur by dynamic contrast-enhanced MRI. AJR Am J Roentgenol. 2011;196(3):637-643. Observational-Dx 12 patients (14 symptomatic hips) To relate intramedullary perfusion of the proximal femur to severity of ONFH by using dynamic contrast-enhanced MRI. Compared with control hips, there was significantly greater peak enhancement in the femoral head in hips of all grades (P<0.001) and in the femoral neck (P=0.001) and intertrochanteric area (P=0.001) in grade 2 hips. The time to peak was significantly delayed in the femoral head in grade 0 hips (P=0.02) and in the intertrochanteric area in grade 2 hips (P=0.003) compared with the controls. 2
40. Geith T, Niethammer T, Milz S, Dietrich O, Reiser M, Baur-Melnyk A. Transient Bone Marrow Edema Syndrome versus Osteonecrosis: Perfusion Patterns at Dynamic Contrast-enhanced MR Imaging with High Temporal Resolution Can Allow Differentiation. Radiology. 283(2):478-485, 2017 05. Review/Other-Dx 32 patients (36 joints, 26 hips, 10 knees) To evaluate perfusion patterns at quantitative dynamic contrast-enhanced MR imaging with high temporal resolution and the derived perfusion maps with high spatial resolution to allow visual interpretation and quantitative evaluation of plasma flow (PF) and mean transit time (MTT) in patients with TBMES and osteonecrosis. Nineteen joints with TBMES and 17 joints with osteonecrosis were evaluated. TBMES joints showed a subchondral elongated area of high PF and low MTT that was surrounded by an area of long MTT and low PF. Osteonecrosis joints showed a subchondral area with low or no detectable PF and MTT adjacent to the joint surface, which was surrounded by a rim of high PF and intermediate MTT. Patterns for TBMES and osteonecrosis did not overlap. A significant difference (P , .001) in PF in the immediate subchondral area was found between TBMES and osteonecrosis; in joints with osteonecrosis, this was comparable to background noise, and therefore, could not be quantified. In the circumscribed rim of high PF and intermediate MTT, which was only found in joints with osteonecrosis, mean 6 standard deviation PF was 18.9 mL/100 mL per minute 6 11.0 and mean MTT was 213.3 seconds 6 56.8. No significant difference between TBMES and osteonecrosis was found for MTT (P = .09) and PF (P = .75) in the surrounding area. 4
41. Mueller D, Schaeffeler C, Baum T, et al. Magnetic resonance perfusion and diffusion imaging characteristics of transient bone marrow edema, avascular necrosis and subchondral insufficiency fractures of the proximal femur. Eur J Radiol. 83(10):1862-9, 2014 Oct. Experimental-Dx 29 patients To evaluate magnetic resonance (MR) perfusion and diffusion imaging characteristics in patients with transient bone marrow edema (TBME), avascular necrosis (AVN), or subchondral insufficiency fractures (SIF) of the proximal femur. Seven patients presented with TBME, 15 with AVN and seven with SIF of the proximal femur. Perfusion imaging showed significant differences for maximum enhancement values (Emax), slope (Eslope) and time to peak (TTP) between the three patient groups (p<0.05). In contrast, no significant differences for ADC values were calculated when comparing TBME, AVN, and SIF patients. 3
42. Pierce TP, Elmallah RK, Jauregui JJ, Poola S, Mont MA, Delanois RE. A current review of non-vascularized bone grafting in osteonecrosis of the femoral head. Curr Rev Musculoskelet Med 2015;8:240-5. Review/Other-Tx N/A To (1) provide a summary of the different surgical techniques and their respective clinical outcomes and (2) evaluate new adjunct therapies. No results stated in abstract. 4
43. Zhang YZ, Cao XY, Li XC, et al. Accuracy of MRI diagnosis of early osteonecrosis of the femoral head: a meta-analysis and systematic review. J. ORTHOP. SURG.. 13(1):167, 2018 Jul 04. Meta-analysis Forty-three studies To evaluate the overall diagnostic value related to magnetic resonance imaging (MRI) in patients with early osteonecrosis of the femoral head. The global sensitivity and specificity of MRI in early osteonecrosis of the femoral head were 93.0% (95% CI 92.0-94.0%) and 91.0% (95% CI 89.0%-93.0%), respectively. The global positive likelihood ratio and global negative likelihood ratio of MRI in early osteonecrosis of the femoral head were 2.74 (95% CI 1.98-3.79) and 0.18 (95% CI 0.14-0.23), respectively. The global DOR was 27.27 (95% CI 17.02-43.67), and the area under the SROC was 93.38% (95% CI 90.87%-95.89%). Good
44. McDonald MD, Sadigh S, Weber KL, Sebro R. A Rare Case of an Osteolytic Bone-infarct-associated Osteosarcoma: Case Report with Radiographic and Histopathologic Correlation, and Literature Review. Cureus 2018;10:e2777. Review/Other-Dx 1 patient To discuss a case of a patient with a humeral bone-infarct, who presented with a presumed benign pathological fracture of the humerus through the bone infarct. No results stated. 4
45. Stacy GS, Lo R, Montag A. Infarct-Associated Bone Sarcomas: Multimodality Imaging Findings. AJR Am J Roentgenol. 205(4):W432-41, 2015 Oct. Review/Other-Dx 258 patients To characterize infarct-associated bone sarcoma and its imaging features. Nine infarct-associated bone sarcomas were found in eight patients: seven malignant fibrous histiocytomas (MFHs) and two osteosarcomas. All occurred in the femur or tibia; multifocal infarction was documented in all patients except one. Sarcomas were commonly associated with a so-called “mature”-type pattern of osteonecrosis—that is, with well-defined calcified margins. Osteolysis of infarct-associated MFHs was often overlooked at initial presentation and was often detected only after pathologic fracture. CT and MRI revealed cortical penetration in all cases; infarct margin disruption was evident, but preservation of fat within the infarct was typical. 4
46. Ahmed N, Sriskandarajah P, Burd C, et al. Detection of avascular necrosis on routine diffusion-weighted whole body MRI in patients with multiple myeloma. Br J Radiol. 92(1097):20180822, 2019 May. Review/Other-Dx 226 patients including 650 whole body MR scans To assess incidental detection of femoral head avascular necrosis on routine whole body MRI including diffusion weighted MRI. 15 patients (6.6%) had typical MR features of avascular necrosis: 2/15 (13.3%) had femoral head collapse, 4/15 (26.7%) had bilateral avascular necrosis and 9/15 (60%) were asymptomatic. 4
47. Albano D, Patti C, La Grutta L, et al. Osteonecrosis detected by whole body magnetic resonance in patients with Hodgkin Lymphoma treated by BEACOPP. Eur Radiol. 27(5):2129-2136, 2017 May. Review/Other-Dx 42 patients To assess the incidence of osteonecrosis in patients who received different chemotherapies. Six out of seven patients (86 %) who received eight BEACOPP and one out of five patients (20 %) treated by four BEACOPP presented osteonecrosis, with a statistically significant difference of frequency between the two groups of patients (p < 0.05); no injury has been reported in patients treated by only ABVD. Among a total of 48 osteonecrotic lesions observed, 48 % were detected in the knee; multifocal osteonecrosis were detected in six out of seven patients (86 %). 4
48. Zhen-Guo H, Min-Xing Y, Xiao-Liang C, et al. Value of whole-body magnetic resonance imaging for screening multifocal osteonecrosis in patients with polymyositis/dermatomyositis. Br J Radiol. 90(1073):20160780, 2017 May. Observational-Dx 129 patients To assess the value of coronal short-tau inversion recovery whole-body MRI (STIR-WBMRI) for screening osteonecrosis in patients with polymyositis (PM)/dermatomyositis (DM). STIR-WBMRI detected osteonecrosis in 15 (11.6%) patients. 38 joints were affected (mean, 2.5 per patient; range, 1-5 joints). Of the 38 joints affected by osteonecrosis, 33 had no clinical symptoms. Among the 12 patients who underwent regional MRI, STIR-WBMRI detected all 10 osteonecrotic sites seen on the regional MRI. The location, shape and size of the osteonecrotic lesions revealed on regional MRI were in accordance with those displayed on STIR-WBMRI. Of the 15 patients with osteonecrosis, 6 performed routine radiography of the affected joints and revealed no osteonecrotic lesions. Follow-up WBMRI detected new osteonecrosis in two patients whose first WBMRI revealed that there was no osteonecrosis in any skeleton. 3
49. Lee B, Lim JY, Lee DM, et al. Computed Tomography Staging of Osteonecrosis of the Femoral Head. Surg Technol Int. 35:417-421, 2019 11 10. Review/Other-Dx 308 patients To determine the prevalence of occult fracture in the necrotic portion among osteonecrotic femoral heads, which were classified as Association Research Circulation Osseous (ARCO) stage 1 or 2 on radiographs. Among the 308 hips, which were classified as stage I or II lesions on simple radiography, fracture inside the necrotic portion was seen in 63 hips (20.5%) on CT scans. Fifty-nine of the 63 patients were followed for two to five years. Further collapse of the femoral head occurred in 41 patients, and 36 of them underwent THA during the follow up. 4
50. Li B, Lei P, Liu H, et al. Clinical value of 3D printing guide plate in core decompression plus porous bioceramics rod placement for the treatment of early osteonecrosis of the femoral head. J. ORTHOP. SURG.. 13(1):130, 2018 May 30. Experimental-Tx 40 patients To evaluate the clinical value and efficacy of three-dimensional (3D) printing guide plate in the process of core decompression plus porous bioceramics rod for the treatment of early ONFH. The surgery time, fluoroscopy time, and intraoperative blood loss in the experiment group was significantly less (P < 0.05) than those in the control group. There was no statistical significance in the accuracy of core decompression and porous bioceramics rod placement between the two groups (P > 0.05). All patients were followed up for 18 months. There was a significant difference between the preoperative and final follow-up HSS scores in both groups (P < 0.05). In addition, there was also a significant difference between the groups in the last follow-up HSS scores (P < 0.05). 1
51. Hatanaka H, Motomura G, Ikemura S, et al. Volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging is associated with disease severity after collapse in osteonecrosis of the femoral head. Skeletal Radiology. 48(8):1193-1200, 2019 Aug. Observational-Dx 40 patients, 63 consecutive hips. 10unaffected hips in 10 patients with unilateral ONFH were used as controls. To evaluate the relationship between the volume of hip synovitis detected on contrast-enhanced magnetic resonance imaging (MRI) and the disease stage of osteonecrosis of the femoral head (ONFH). The mean synovial volume was significantly larger in ONFH hips (8,020 ± 6,900 mm3) than in controls (910 ± 1,320 mm3; p = 0.001). The area of synovitis in the anterior portion of the hip joint was double (mean: 2.17 ± 1.77) that in the posterior portion. The volume of synovitis was small in pre-collapse-stage hips (stage 1: 680 ± 690 mm3, stage 2: 1,460 ± 1,200 mm3), but significantly larger in post-collapse-stage hips (stage 3A: 7,820 ± 4,490 mm3, stage 3B: 13,850 ± 7,110 mm3; p < 0.001). 3
52. Ha AS, Wells L, Jaramillo D. Importance of sagittal MR imaging in nontraumatic femoral head osteonecrosis in children. Pediatr Radiol. 2008;38(11):1195-1200. Observational-Dx 34 patients To hypothesize that sagittal MRIs show a greater degree and angular span of femoral head collapse than coronal images. Sagittal MRIs showed 29% maximal femoral head radius collapse, whereas coronal images showed 16% collapse (P<0.001). Sagittal images showed a larger angular span of collapse (115 degrees) than coronal images (55 degrees, P<0.001). Sagittal images showed greater epiphyseal bone loss in the anterior than in the posterior portion (P<0.001), whereas coronal images did not show a significant difference in bone loss between the medial and lateral portion (P=0.32). 2
53. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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