It has been suggested that decreased replication capacity of mesenchymal stem cells (MSCs) or decreased MSCs activity in the bone marrow is related to nontraumatic osteonecrosis (ON). However, little is known about differentiation ability of MSCs according to the risk factor of nontraumatic ON. We hypothesize that differentiation abnormalities in MSCs of the bone marrow of the proximal femurs might be related to nontraumatic ON of the femoral head. The purpose of this study was to investigate the osteogenic and adipogenic differentiation ability of MSCs in patients with nontraumatic ON of the femoral head. We examined the differentiation ability of MSCs in cultures derived from the bone marrow of the proximal femurs obtained from 10 patients with hip osteoarthritis (OA) and 37 patients with nontraumatic ON of the femoral head undergoing hip replacement surgery. We analyzed the osteogenic and adipogenic differentiation ability of MSCs according to the risk factor [alcohol-induced (15 patients), idiopathic (12 patients) and steroidinduced (10 patients)] of nontraumatic ON of the femoral head separately and compared it with patients with hip OA. The osteogenic activity was measured as the extracellular matrix calcification by alizarin red S staining and the alkaline phosphatase activity, and the adipogenic activity was measured as the accumulation of Oil red O-positive lipid vacuoles. The osteogenic differentiation ability of MSCs in patients with alcohol-induced and idiopathic ON was significantly reduced compared with that in patients with OA (p < 0.05 and p < 0.05, respectively). In patients with steroidinduced ON, the osteogenic differentiation ability was found to be increased, but the difference was not statistically significant. The adipogenic differentiation ability of MSCs was not significantly changed in patients with alcohol-induced, idiopathic, and steroid-induced ON compared to patients with OA. Our results indicate that altered osteogenic differentiation ability in MSCs is related to nontraumatic ON of the femoral head and the differentiation potential of MSCs in patients with nontraumatic ON differs according to its risk factor. ß

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These results suggest that the ERα gene polymorphism using XbaI restriction enzyme influences the perception of back pain in patients with DS.