The Journal of Bone and Joint Surgery (American). 2007;89:2460-2468.
doi:10.2106/JBJS.F.01421
© 2007 The Journal of Bone and Joint Surgery, Inc.
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Association Between the T-786C eNOS Polymorphism and Idiopathic Osteonecrosis of the Head of the Femur

Charles J. Glueck, MD1, Richard A. Freiberg, MD2, Jennifer Oghene, BS3, Robert N. Fontaine, PhD3 and Ping Wang, PhD1

1 Cholesterol Center, ABC Building, 3200 Burnet Avenue, Cincinnati, OH 45229. E-mail address for C.J. Glueck: glueckch{at}healthall.com
2 Orthopedic Surgery Service, VA Hospital, 3200 Vine Street, Cincinnati, OH 45220
3 MDL Laboratories, 3130 Highland Avenue, 3rd Floor, Suite 3315, Cincinnati, OH 45219-2374

Investigation performed at the Cholesterol Center, Jewish Hospital of Cincinnati, the Orthopedic Surgery Service, VA Hospital, and the MDL Laboratories, Cincinnati, Ohio

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: Nitric oxide regulates bone turnover by osteoblasts and osteoclasts. Nitric oxide production is impaired by the T-786C eNOS single nucleotide polymorphism, with a substitution of the nucleotide thymine by cytosine at a locus 786 base pairs upstream of the eNOS gene. This leads to vasoconstriction, platelet aggregation, reduced angiogenesis, and reduced bone formation, all of which may be associated with osteonecrosis of the hip. We studied relationships between the T-786C eNOS polymorphism and idiopathic and secondary necrosis of the head of the femur in order to better understand the pathophysiology of osteonecrosis.

Methods: With use of polymerase chain reaction methodology, the T-786C eNOS polymorphism was compared in ninety-five patients with femoral head necrosis (including thirty-six nonsmokers with idiopathic necrosis and fifty-nine patients with secondary necrosis) and seventy-two healthy normal adult controls.

Results: Homozygosity for the mutant eNOS allele (TT) was present in eight (22%) of thirty-six patients with idiopathic osteonecrosis as compared with one (3%) of thirty-six race, gender, and age-matched controls; heterozygosity (TC) was present in nineteen patients (53%) as compared with ten controls (28%); and the wild-type normal genotype (CC) was present in nine patients (25%) as compared with twenty-five controls (69%) (p = 0.0004). Logistic regression revealed that the T-786C eNOS mutant allele was positively associated with idiopathic osteonecrosis of the femoral head (odds ratio, 6.0; 95% confidence interval, 2.51 to 14.4). The fifty-nine patients with secondary osteonecrosis did not differ from fifty-two race, gender, and age-matched controls in terms of the distribution of the T-786C eNOS polymorphism (p = 0.19) or in terms of mutant allele frequency (30% compared with 21%; p = 0.15). The thirty-six patients with idiopathic osteonecrosis differed from the fifty-nine patients with secondary osteonecrosis in that they were more likely to have mutant eNOS genotypes (p = 0.033) and to have a higher mutant T allele frequency (49% compared with 30%; p = 0.009).

Conclusions: The T-786C eNOS polymorphism and resultant reduction of nitric oxide production is associated with, and may contribute to, the pathogenesis of idiopathic osteonecrosis of the femoral head.

Level of Evidence: Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.


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C. J. Glueck, R. A. Freiberg, S. Boppana, and P. Wang
Thrombophilia, Hypofibrinolysis, the eNOS T-786C Polymorphism, and Multifocal Osteonecrosis
J. Bone Joint Surg. Am., October 1, 2008; 90(10): 2220 - 2229.
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