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Avascular necrosis (AVN) of the capitate is a rare condition. A case report is presented with a review of the literature.

The case of a 25-year-old man with osteonecrosis of the hamate is reported. He had pain and swelling in his right wrist. The diagnosis was accomplished with plain radiographs as well as with MRI. The case was treated surgically that included resection of the necrotic bone. The occured cavity was filled with autogenous cancellous bone graft. In addition, capito-hamate arthrodesis was performed. Histopathological examination following the operation demonstrated avascular necrosis of the hamate. The arthrodesis was obtained four months after the operation.

The purpose of the study was to compare angiogenic response of isolated saphenous and epigastric arteriovenous bundles in avascular environment, in an in-vivo model. Saphenous and epigastric bundles of 20 rats were dissected and ligated distally. The bundles were implanted into silicone tubing to create a biologically neutral environment. Gross and histologic examination was performed at different intervals. No thrombus was detected in any of bundles prior to 24 hours. An adherent thrombus was seen at 24 hours in all ligated saphenous bundles; it persisted at three weeks with no evidence of neovascular sprouting. The ligated epigastric bundles remained patent with evidence of neovascular sprouting. The saphenous vessels are more likely to thrombose and do not show vascular proliferation when placed in an isolated environment, whereas the epigastric vessels are likely to remain patent and show vascular proliferation.

Kienböck's disease is known for its difficulty in being diagnosed and treated at early stages; option treatments are few and most of them quite aggressive. The author describes his experience with arthroscopic assisted lunate bone grafting. Three patients with diagnosis of stage I avascular necrosis of the lunate (average age: 45 years), were treated. Before surgical procedure, the patients underwent to a conservative treatment. After harvesting the bone graft from the volar surface of the radius, arthroscopic bone grafting was performed.

At an average follow-up of 13.5 months (9–15), all the patients show a normal density of the lunate and no arthritic changes in radiographs. The MRI confirmed the lunate vascularity.

The number of patients is definitely small, due also to the rarity of the disease and the difficulty in diagnosis, but, despite the very high learning curve, could be the proper first choice of treatment.

Simultaneous avascular necrosis of multiple carpal bones is rare. Concomitant avascular necrosis of scaphoid and lunate has been reported only once. We report one more case of this rare condition which can be a cause of wrist pain. Steroid intake is a known risk factor for avascular necrosis but in our case the patient had been taking herbal medicines for joint pain the composition of which was not known. Probably the presence of steroid in these medicines was the cause of avascular necrosis in this case.

We report a case of avascular necrosis of the scaphoid, lunate and triquetrum in a young 21- year- old patient, after a purely ligamentous peri-lunate dislocation of the wrist. He presented with a Mayfield III peri-lunate dislocation after a road traffic accident and underwent an open reduction and internal fixation. Post-operatively, the scapho-lunate gap widened after removal of the temporary K-wires, and he gradually developed avascular necrosis of the scaphoid, lunate and triquetrum, and osteoarthritis of his wrist. We present this unusual case of simultaneous avascular necrosis of multiple carpal bones and discuss the possible risk factors and subsequent management plans for this complex injury. Our patient has no identifiable contributing factors to developing avascular necrosis. We suspect that the violence of the injury and surgery may have compromised the circulation, and advise caution when treating and counseling these patients pre-operatively.

Systematic studies of treatment options for femoral head osteonecrosis have been hindered by the lack of an animal model that mimics the human event of femoral head collapse. The (bipedal) emu model of osteonecrosis has proven to progress to collapse following an external insult. Since osteonecrosis clinically has multiple etiologies, various alternatives are seemingly appropriate to initiate lesions for research purposes. This study compared osteonecrosis initiated by a local cryoinsult, to that initiated by a large systemic dose of steroid (methylprednisolone acetate), and by a combination of steroid and cryoinsult. One year post-insult, the animals were sacrificed and their femoral heads harvested. A custom-written computer program was used to expedite analysis of the global distribution of histologically apparent osteonecrosis, as determined by the Ficat scale. Following whole-head analysis, grade distributions were calculated, and a measure of spatial clustering of histologic abnormality was calculated using Moran's I statistic. Normal femoral heads showed very small amounts of histological abnormality, and no significant spatial clustering. Femoral heads receiving isolated cryoinsult had a greater incidence of high-grade abnormality, as well as statistically significant spatial clustering of that abnormality. Steroid-only animals had a higher percentage of diffuse, low-grade abnormality. The group receiving both steroid and cryoinsult showed the highest overall abnormality, with statistically significant clustering of that high-grade abnormality. Cryoinsult, both in isolation and in combination with a steroid regimen, appeared necessary to mimic the clinically typical focal lesions of osteonecrosis.

Objectives: Avascular necrosis (AVN) of the femoral head is a pathologic process resulting from interruption of blood supply to bone. The aim of this paper is to describe the technical aspects and outcome of a modified technique of core decompression and bone graft injection for the treatment of AVNFH. Methods: A total of 20 patients (26 femoral head AVN) Ficat stage I to early III were treated using core decompression kit followed by injection with bone graft material. Nine hips were stage III, 16 stage II and 1 stage I. Average operative time was 25min. Results: At a median follow-up of 48 months, 20 hips (77%) had almost complete pain relief while pain persisted in 6 hips (23%). All patients who demonstrated clinical response exhibited radiological stabilization of disease. The mean Harris hip score for all patients’ prior and following surgery were 41 and 85, respectively ($p<0.0001$). Conclusions: Femur head decompression using core decompression kit followed by bone substitute injection can result in long-term pain relief and prevent progression of AVN in the majority of patients.

Background: In middle-aged patients, treatment of femoral neck fractures is still debated between osteosynthesis and replacement. Describing predictive factors is essential to choose the appropriate treatment for each patient. The aim of this study was to describe risk factors for avascular necrosis (AVN) of the femur head in patients with femoral neck fractures treated with three cannulated screws. Methods: We conducted a retrospective study of 91 patients between January of 2011 and February of 2017. Fractures were classified according to Garden and Pauwels classifications, fracture displacement was measured in millimetres (mm), quality of reduction was classified as anatomical or not anatomical; all post-operative radiographs were classified with Garden Alignment Index (GAI). Demographic data were recorded and analyzed. Results: AVN was found in six cases (6.6%). The Garden Classification ($p=0.029$), GAI classification ($p=0.008$), fracture displacement in mm ($p=0.015$) and anatomical reduction ($p=0.016$) were significantly associated with AVN. The most important risk factor for AVN was suboptimal reduction in axial view evaluated with GAI ($p=0.004$). One case of AVN occurred in patients with GAI considered excellent (71.42%); no AVN occurred in patients with anatomical reduction (47.2%). Conclusions: Anatomical reduction in patients with femoral neck fractures treated with cannulated screws is mandatory. The degree of displacement before surgery influences the outcome but post-operative anatomical reduction, especially in the lateral view, is the most important predictive factor for the outcome: decreasing the Lateral Garden Angle (LGA) from 180^∘ increases significantly the risk for AVN.

Introduction: Classification systems for femoral neck fractures are very helpful for surgeons in order to choose the correct treatment. The purpose of this study was to verify the reliability and reproducibility in the most used classifications for proximal medial femoral fracture: Garden and Pauwels classifications. Materials and methods: Five surgeons independently classified 82 intra-capsular femur fractures treated with 3 cannulated screws using Pauwels and Garden classifications measured on pre- and post-operatively X-Rays. Inter-observer agreement was calculated for both classifications using the multi-rater Fleiss’ kappa; intra-observer agreement from pre-operative to post-operative XRs for Pauwels classification was also calculated with the same method. Results: Only six cases of AVN were registered. The inter-observers agreement based on pre-operative X-rays was moderate for Pauwels classification ($\kappa$ 0.528) and slightly lower for Garden classification ($\kappa$ 0.448); but in the simplified Garden classification (type I and II not displaced vs type III and IV displaced) the agreement measured was almost perfect ($\kappa$ 0.908). The intra-observer agreement for Pauwels classification was moderate ($\kappa$ 0.456). All the results were statistically significant. Conclusions: This is the first study evaluating the Pauwels angle on both preoperative and postoperative X-rays to assess their reproducibility. Garden classification has a really high reliability and reproducibility in evaluating displaced and not displaced fractures and consequently can be helpful in choosing the correct treatment. Pauwels classification has a lower inter and intra-observer agreement.

Avascular necrosis of the metacarpal head is a rare entity. Surgical interventions, such as curettage, bone-grafting, and osteotomy, have been reported in symptomatic patients. We present a patient who underwent pyrolytic carbon hemiarthroplasty of the metacarpal head and had satisfactory outcomes at 1-year follow-up.