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Vol. 14. Issue 2.
Pages 122-123 (March - April 2018)
Vol. 14. Issue 2.
Pages 122-123 (March - April 2018)
Letter to the Editor
DOI: 10.1016/j.reumae.2017.04.005
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Prevalence of Risk Factors for the Development of Avascular Hip Necrosis in a Third-level Hospital
Prevalencia de los factores de riesgo para el desarrollo de necrosis avascular de cadera en un hospital de tercer nivel
Elena Cristina de Sautu de Borbón
Corresponding author

Corresponding author.
, Montserrat Morales Conejo, Juan Manuel Guerra Vales
Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain
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Tables (1)
Table 1. Risk Factors for Avascular Hip Necrosis.
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To the Editor,

Avascular hip necrosis (AHN) is characterized by the death of osteocytes and of the bone marrow caused by interruption of the blood supply to the femoral head.1–3

It commonly affects young adults.2,4,5 In the United States, the incidence is estimated to be between 10,000 and 30,000 cases each year, accounting for 5%–12% of the total hip arthroplasties performed to treat patients who have AHN.2,4,6–8 Despite the identification of a number of risk factors (RF), the etiology and pathogenesis of the disease remain unclear. A number of proposals have been made, including ischemia, direct cell toxicity and changes in the differentiation of mesenchymal stem cells.4,6

Given the impact of this disease, which has an insidious onset and shows no clear symptoms or signs, it is necessary to be aware of those RF that promote it in order to maintain our vigilance in these patients. That will enable early diagnosis and the establishment of the necessary preventive measures and the proper treatment strategies.1,2

On this basis, the objective of our study was to estimate the prevalence of the different RF for AHN in patients admitted to Hospital Universitario 12 de Octubre in Madrid, Spain. We included, from January 2010 to December 2015, a total of 129 patients with a diagnosis of AHN. The mean age±standard deviation was 58.35±15.33 years; 56.6% were men. The diagnostic criteria to define the presence of AHN were mainly obtained from the results of imaging studies. The study was approved by the clinical research ethic committee of our hospital.

The most prevalent RF were tobacco use (n=57; 44.2%) and dyslipidemia (n=46; 35.7%), which we consider to be associated. Among the RF with the greatest etiological burden for the development of AHN, the most prevalent were corticosteroid therapy (n=37; 28.7%), alcoholism (n=26; 20.2%) and previous traumatic injury (n=20; 15.5%). Of the 18 patients (13.9%) with autoimmune and/or inflammatory disease, 3 (16.7%) had systemic lupus erythematosus. The 3 were being treated with corticosteroids and 2 of the 3 were positive for antiphospholipid antibodies. In this respect, Gontero et al.9 found no differences in the total accumulated dose, daily dose and duration of steroid therapy or the presence of antiphospholipid antibodies.

In 17 patients (13.2%), no RF was identified (Table 1). However, there were patients with several RF, with an accumulation of up to 6 in 1.6%. The most prevalent finding was 2 and 3 RF associated with 32 cases (24.8%) and with 27 cases (20.9%), respectively.

Table 1.

Risk Factors for Avascular Hip Necrosis.

≤50 years
>50 years
Tobacco use  57 (44.2%)  24 (52.2%)  33 (39.8%)  .198 
Dyslipidemia  46 (35.7%)  20 (43.5%)  26 (31.3%)  .184 
Corticosteroid therapy/hypercortisolisma  37 (28.7%)  17 (37%)  20 (24.1%)  .155 
Alcoholism  26 (20.2%)  13 (28.3%)  13 (15.7%)  .11 
Traumatic injury  20 (15.5%)  4 (8.7%)  16 (19.3%)  .133 
Autoimmune/inflammatory disease  18 (13.9%)  8 (17.4%)  10 (12.1%)  .434 
Diabetes mellitus  13 (10.1%)  3 (6.5%)  10 (12%)  .377 
Liver cirrhosis  13 (10.1%)  6 (13%)  7 (8.4%)  .543 
Transplantation  11 (8.5%)  4 (8.7%)  7 (8.4%)  1.00 
HIV  10 (7.8%)  5 (10.9%)  5 (6%)  .327 
Chemotherapy  9 (7%)  6 (13%)  3 (3.6%)  .068 
Thrombophilia  8 (6.2%)  3 (6.5%)  5 (6%)  1.00 
Radiotherapy  6 (4.7%)  4 (8.7%)  2 (2.4%)  .186 
Pro-embolic phenomenon  2 (1.6%)  0 (0%)  2 (2.4%)  .538 
Myeloproliferative syndrome  1 (0.8%)  0 (0%)  1 (1.2%)  1.00 
Unknown  17 (13.2%)  1 (2.2%)  16 (19.3%)  .006 

A case of adrenocorticotropic hormone-dependent Cushing syndrome.

HIV, human immunodeficiency virus.

The sample was divided into 2 groups to study the differences between the younger and older patients, randomly setting 50 years as the cutoff point. We found that there was an absence of known RF in the individuals over 50 years of age, resulting in a statistically significant difference (P=.006).

As other authors have indicated, this disease has a gradual onset, without specific symptoms or signs, meaning that the diagnosis is established late.2 Malizos et al.2 mention that, given the numerous associated factors that have recently been described, it is now less common to classify osteonecrosis as idiopathic. The results of our study concur in terms of our findings in the group of patients aged 50 years or less (2.2%). The prevalence of idiopathic AHN in patients over the age of 50 years in our series (19.3%) is similar to that reported by other authors (20%–25%).1,8,10 It is certain that, although this study is retrospective, it has its limitations. For example, missing information because these RF are not recorded in the medical records, contributing to the number of patients without associated factors. In our series, the most prevalent of the RF associated with AHN were tobacco use, dyslipidemia, corticosteroid therapy and alcoholism. Knowledge and detection of the RF associated with this disease will aid in taking preventive measures to delay its development and improve the prognosis.

X.S. Wang, Q.Y. Zhuang, X.S. Weng, J. Lin, J. Jin, W.W. Qian.
Etiological and clinical analysis of osteonecrosis of the femoral head in Chinese patients.
Chin Med J, 126 (2013), pp. 290-295
K.N. Malizos, A.H. Karantanas, S.E. Varitimidis, Z.H. Dailiana, K. Bargiotas, T. Maris.
Osteonecrosis of the femoral head: etiology, imaging and treatment.
Eur J Radiol, 63 (2007), pp. 16-28
Joint Surgery Group of the Orthopaedic Branch of the Chinese Medical Association.
Guideline for diagnostic and treatment of osteonecrosis of the femoral head.
Orthop Surg, 7 (2015), pp. 200-207
C.G. Zalavras, J.R. Lieberman.
Osteonecrosis of the femoral head: evaluation and treatment.
J Am Acad Orthop Surg, 22 (2014), pp. 455-464
M.S. Lee, P.H. Hsieh, C.H. Shih, C.J. Wang.
Non-traumatic osteonecrosis of the femoral head – from clinical to bench.
Chang Gung Med J, 33 (2010), pp. 351-360
F.A. Petrigliano, J.R. Lieberman.
Osteonecrosis of the hip: novel approaches to evaluation and treatment.
Clin Orthop Relat Res, 465 (2007), pp. 53-62
D.W. Zhao, M. Yu, K. Hu, W. Wang, L. Yang, B.J. Wang, et al.
Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the Chinese population: results from a nationally representative survey.
Chin Med J, 128 (2015), pp. 2843-2850
J. Moya-Angeler, A.L. Gianakos, J.C. Villa, A. Ni, J.M. Lane.
Current concepts on osteonecrosis of the femoral head.
World J Orthop, 6 (2015), pp. 590-601
R.P. Gontero, M.E. Bedoya, E. Benavente, S.G. Roverano, S.O. Paira.
Osteonecrosis in systemic lupus erythematosus.
Reumatol Clin, 11 (2015), pp. 151-155
C. Zalavras, Z. Dailiana, M. Elisaf, E. Bairaktari, P. Vlachogiannopoulos, A. Katsaraki, et al.
Potential aetiological factors concerning the development of osteonecrosis of the femoral head.
Eur J Clin Invest, 30 (2000), pp. 215-221

Please cite this article as: de Sautu de Borbón EC, Morales Conejo M, Guerra Vales JM. Prevalencia de los factores de riesgo para el desarrollo de necrosis avascular de cadera en un hospital de tercer nivel. Reumatol Clin. 2018;14:122–123.

Copyright © 2017. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Reumatología Clínica (English Edition)

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