Avascular Necrosis
Transcript of Avascular Necrosis
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Update in Update in Osteonecrosis of Osteonecrosis of
Femoral HeadFemoral Head
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Scope Scope
DefinitionDefinition EtiologyEtiology PathogenesisPathogenesis DiagnosisDiagnosis TreatmentTreatment
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Definition Definition
Disease of impaired osseous blood flow in which a circumscribed area of bone becomes necrosis
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EtiologyEtiology
Traumatic Non-traumatic
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Steroid usage Alcohol Blood disease
Sickle cell anemia Hypofibrinolysis
Caisson disease Connective tissue disease Idiopathic 15-20%
EtiologyEtiology (Non-traumatic)(Non-traumatic)
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EtiologyEtiology Steroid usage
SLE incidence 15-44% Oinuma K.
คนไข้� SLE 72 ราย high dose (>30mg/d) พบ AVN 44% ใน 3 เดื�อน
Osteonecrosis in patients with systemic lupus erythematosus develops very early after starting high dose corticosteroid treatment. Annals of Rheumatic Diseases.2001;60(12):1145-8.
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EtiologyEtiology
Steroid usage - 6-8 years (range 1-19) - Kidney transplant AVN 4.5% - 80% Bilateral
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EtiologyEtiology Koo KH, et al
ผู้��ป่�วย 22รายเกิ�ดื AVN เฉลี่��ย 5928 mg(1,800-15,505 mg) Average 5.3 m.(1-16 m) 21/22 รายเป่�นใน 1 ป่�แรกิ
Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment. Clin Rheumatol 2002 Aug:21(4):299-303
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Steroid usageSteroid usage
Pathophysiology: 1)Direct cellular toxicity
2)Abnormal fat metabolism-Adipocyte hypertrophy-Fat embolism
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EtiologyEtiology
Marston SB, et al Solid organ transplant (kidney+liver) 52 pt. AVN femoral head 11% (20%) AVN in 10 months MRI screening in the first year
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EtiologyEtiology Ferrari P, et al.
Homozygous 4G/4G PAI-1 genotype. Ries MD.
HIV infection (risk factor of AVN)
Association between human immunodeficiency virus and osteonecrosis of the femoral head. J Arthroplasty 2002 Feb: 17(2):135-9
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PathogenesisPathogenesis
Infarction theory Fat embolism theory Accumulative cell stress theory Progressive ischemia theory Immunologic reaction
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DiagnosisDiagnosis History Physical examination Laboratory test
CBC, ESR R/O infection Cortisol level
Radiological examination
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History History
A high index of suspicious is essential
An associated risk factor The most common presenting
symptom is a deep pain in the groin
Exacerbated by activity
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Physical examinationPhysical examination
Pain on internal rotation Decrease ROM Hip abductor weakness (G.
medius) Shortening of limb
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Plain film X-Plain film X-rayray
AP pelvis, frog leg
Crescent sign Secondary OA
change
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Technetium bone scan (Tc Technetium bone scan (Tc 99)99)
Preradiographic phase AVN Decrease uptake Sensitivity and specificity <
MRI SPECT (Single-photon emission
computed tomography) sensitivity 100% in renal
transplant pt.
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BONE SPECTBONE SPECT
32 AVN of femoral head SPECT detect 32/32 -> 100% sensitivity MRI detect 21/32 -> 66%
sensitivity
(The Journal of Nuclear Medicine. 2002;43(8):1006-1011)
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MRIMRI Investigation of choice Decrease signal Screening T1 coronal scan
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CT scanCT scan Arthroscopic examinationArthroscopic examination
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Ficat’s stagingFicat’s staging Clinical Plain
film MRI
Stage O No pain normal abnormal
Stage I pain normal +
Stage II + crescent’sign
+
Stage III + Collapsed femoral head
+
Stage IV + Narrow joint space+acetabulum
+
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normalnormal scleroticsclerotic
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Crescent signCrescent sign Collapse Collapse
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AcetabularAcetabular involvementinvolvement
Severe jointSevere jointdestructiondestruction
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TreatmentTreatment Conservative
- Temporally non weight bearing
Electrical stimuli Surgery
Joint preserving procedure
prosthetic replacement
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TreatmentTreatment
Conservative treatment stage I-II NWB with crutches (6 wks) analgesic+exercise F/U 2 years 80% poor result
Musso, et al. Result of conservative management of osteonecrosis of the femoral head. A retrospective review. Clin Orthop 1986 June; 207: 209-215
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Result of nonoperative RxResult of nonoperative Rx 55 AVN / nonoperative Rx
92% radiographic progression 84% arthroplasty, Av. Time 21
months
(Steinberg. Clin Orthop;1989) 15 AVN / nonoperative Rx
100% collapse, Av. Time 23 months (Bradway and Morrey. J
Arthroplasty;1993)
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Joint preserving procedureJoint preserving procedure
Core decompression Osteotomy Free vascularized fibular/ iliac g
raft Arthrodesis Arthroscopic debridement
(+core)
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TreatmentTreatment
Core Decompression Decrease BMP (bone marrow
pressure) Increase venous drainage Promote vascular ingrowth Bone graft, autologous bone marrow Treatment of choice stage I-II
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Core DecompressionCore Decompression
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Result of core Result of core decompressiondecompression
133 AVN, stage I+II, F/U 9.5 years90% successful clinical result79% no radiographic progression (Ficat. JBJS;67B:3-9:1985)
204 AVN, F/U 3 yearsno additional operative Rx was necessary
96% stage I77% stage II60% stage III
(Zizic and Hungerford. Textbook of Rheumatology Ed 2, Vol.2:1689-1710)
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Electrical stimulationElectrical stimulation Goal: Enhance bone formation and fracture healing Alone or as an adjunct to other surgical procedure PEMP (pulsing electromagnetic fields)
-more effective than symptomatic Rx in precollapse and minimally collapse
-as effective as core decompression in precollapse
-more effective as core decompression in minimally collapse
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OsteotomyOsteotomy
Shift the necrotic segment out of the region of major weight bearing and replace it with normal bone and cartilage
Early to intermediate stage that acetabular cartilage is unaffected
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Femoral OsteotomyFemoral Osteotomy Candidate
< 40 years old Small lesion (< 200
degrees) Mobile hip No longer taking steroid
Difficulty for THR Removal of implants after
union
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Result ofResult of Ostetomy Ostetomy Sugioka Y ( Sugioka Y (CORR.CORR.19198484)
158 113hip (ราย ) มี� success rate 86-95 %
(1992 , 295 pts, 79%, ave F/U 11 yrs)
Inao S (CORR. 1999) 14 hips( 12 ราย ) F/U
- 1017 ป่� มี� 3 ราย >THR ถ้�า Collapse 2<mm จะไดื�ผู้ลี่ ดื�ที่�� 15 ป่�
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TreatmentTreatment Vascularized bone graft - fibular, iliac crest - revascularized
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Vascularized bone graftVascularized bone graft Goal:
Decompress the femoral head Remove necrotic bone Fill necrotic defect with
osteoinductive cancellous bone graft Support subchondral bone with strut
graft Enhance revascularized process
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Vascularized bone graftVascularized bone graft
Disadvantage: Technical demand A few centers have significant experience with this technique Well-trained microvascular surgeon More complication
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Vascularized bone graftVascularized bone graft
Advantage: The result is better than core
decompression in stage II, III
(Ficat classification)
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Result of Vascularized bone Result of Vascularized bone graftgraft
-Urbaniak JR (JBJS. 77 A.1995) mean survival rate= 88% ในผู้��ป่�วย
stage I , II Judet H (CORR.2001) FU 18 ป่�
พบว%า 80% ข้องผู้��ป่�วย 60 ราย stage I,II ย'งไดื�ผู้ลี่ดื�อย�%
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Prosthetic replacement Prosthetic replacement surgerysurgery
Limited resurfacing arthroplasty
Resurfacing arthroplasty Hemiarthroplasty Total hip replacement
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Limited Resurfacing Arthropl Limited Resurfacing Arthroplastyasty
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2001Mont MA (CORR. , J. Arthroplasty2001
ผู้��ป่�วย 30 รายใน stage III, IV เป่ร�ยบเที่�ยบกิ'บผู้��ป่�วยอ�กิ 30 ราย ใน stage เดื�ยวกิ'น แต่%ใช้�ว�ธี�กิารเป่ลี่��ยนที่'+งข้�อ
7FU ป่� พบว%า 90% แลี่ะ 93% ข้องที่'+ง 2 ว�ธี� ย'งคงใช้�ไดื�ดื�อย�%
Siguier T (CORR.2001) ผู้��ป่�วยstage III 26 ข้�อ แลี่ะ stage IV 10 ข้�อ พบว%าที่��FU 4 ป่� มี� 9 ราย ที่��ต่�องเป่ลี่��ยนเป่�น THR
Result of Result of Limited Resurfacing Limited ResurfacingArthroplastyArthroplasty
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Hemisurface arthroplastyHemisurface arthroplasty
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Hemisurface or partial Hemisurface or partial resurfacing arthroplastyresurfacing arthroplasty
Time-buying procedure for young and active patient
Adequated bone quality and relative normal articular cartilage
Bone stock preservation and intact intramedllary canal
Survivorship 81% at 5.1 years Survivorship 61% at 10 years (Amstutz HC. Semin Arthroplasty ;9:261,1998)
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HemiarthroplasHemiarthroplastyty
Chan YS (CORR.2000) ได้�เปรี�ยบเที�ยบผลการี
รี�กษาโด้ยใช้� Bipolar ก�บ THR ในคนไข้�คนเด้�ยวก�นพบว�า 24 ใน
28 ข้�างข้อง bipolar และใน 23
ใน 28 ข้�างข้อง THR ได้�ผลเป�นที� พอใจเมื่# อติ%ด้ติามื่ผลไปเฉล� ย 6.
4 ป'
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Treatment
Total hip arthroplasty - femoral head + acetabulum - stage IV - survivorship in young patient is
less than in older patient
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Total Hip Arthroplasty
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Total Hip Arthroplasty
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Ficat Stage I
Rx. 1. Conservative 2. Core decompression
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Ficat stage II
Rx. 1. Conservative 2. Core decompression 3. Others
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Ficat stageIII
Rx. 1. Conservative 2. Hemi arthropl asty 3 . Others
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Ficat stageIV
Rx. 1.Conservative 2. THR 3.Arthrodesis
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Thank You