Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB, MNAMS,FELLLOWSHIP PAEDIATRIC...
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Transcript of Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB, MNAMS,FELLLOWSHIP PAEDIATRIC...
AVASCULAR NECROSIS AVASCULAR NECROSIS FEMORAL HEADFEMORAL HEAD
By :
Dr. Rajat MalotDr. Rajat Malot
Assistant ProfessorAssistant Professor
SMS Medical college SMS Medical college
JaipurJaipur
How to Approach a patient with Hip Pain
• Detailed History :
Trauma ,Drug intake,Any other joint involvement,Constitutional symptoms,Any metabolic or endrocrine disorder
• Pain : Exact site, mode of onset,Radiation
• Age
• Gait : Antalgic /Trendelenberg
Anterior Hip pain or Groin pain
Lateral pain or Trochanteric pain
Posterior hip pain
Rule out: hip fracture, septic joint, and avascular necrosis
Other causes:OA, RA, iliopectineal bursitis
Rule out: hip fracture, bone tumor, referred pain from lumbar disc herniation
Other causes: trochanteric bursitis,OA, radiating fromlumbar disc or facet disease
Rule out: sciatic nerve irritation ,sacroiliitis due to spondyloarthropathy, lumbardisc or facet disease
Other causes:muscle strain
No distinguishing Clinical Features/ High index of suspicion
Asymptomatic Pain gradual & insidious in nature
Range Of Motion (ROM) ; patient may walk with a limp
Radiographic findings may appear after a delay of several months to years following the onset of symptoms
CLINICAL PRESENTATIONCLINICAL PRESENTATION
Focal over the groin / hip or it may radiate to the buttocks, anteromedial thigh or knee
Induced mechanically by standing & walkingstanding & walking & may be eased by rest
May be very intense, throbbing, deep & often intermittentintense, throbbing, deep & often intermittent
Worsened by coughingcoughing & at nightnight
40% of patients have night pain asso. with morning stiffness
A ClickClick may be heard when the patient rises from a sitting position or on external rotation of an abducted hip
Characteristics Of PainCharacteristics Of Pain
ROM may be diminished, especially after collapse of the collapse of the femoral headfemoral head
ROM may be limited, especially in flexion, abduction & internal flexion, abduction & internal rotationrotation
GaitGait :- Patients may walk with a limp.
The Trendelenburg signThe Trendelenburg sign may be PositivePositive
To be diagnosed at an early stage, high index of suspicion, especially true with U/L involvement because of the high risk of the dev. of AVN in the C/L Hip
Range Of MotionRange Of Motion
BLOOD SUPPLY OF FEMORAL HEADBLOOD SUPPLY OF FEMORAL HEAD The principal sources are the Lateral Epiphyseal Vessels Lateral Epiphyseal Vessels
(LEVs). (LEVs).
LEVs Posterior Superior Retinacular Vessels (PSVs)
Medial Femoral Circumflex Artery Profunda-
Femoris Artery.
LEV supplies lateral and central thirds of the femoral head When patent, the Artery of Ligamentum Teres(ALT)Artery of Ligamentum Teres(ALT) supplies
medial third of the femoral head.
Branches of LEVs & ALT anastomose at the junction of central & medial 1/3 of the femoral head
BLOOD SUPPLY OF FEMORAL HEADBLOOD SUPPLY OF FEMORAL HEAD
lateral circumflex A.
Medial circumflex A.
Blood Supply in Paediatric Age Gp.Blood Supply in Paediatric Age Gp.
Till 4-7 years of age4-7 years of age, the vascular anatomy in a transitional stage of development.
The ALT does not penetrate the epiphysis of the femoral head until 9 or 10 years of age.
The Medial Circumflex Artery (br.of Profunda Femoris Artery), penetrates into the femoral proximal metaphysis but is prevented from passing into the femoral epiphysis by the growth plate.
The blood supply to the femoral head is especially vulnerable during this time.
AVN HISTORYAVN HISTORY
KonigKonig (1888) => first described the condition coined the term Osteochondritis Dissecans
Haenish Haenish (1925) => first case of idiopathic ischemic necrosis of the femoral head in an adult
Arterial OcclusionArterial Occlusion (1940) was postulated as the cause of the necrosis.
PietrograndiPietrograndi (1957) => AVN d/t Steroid therapy Steroid therapy
AVASCULAR NECROSISAVASCULAR NECROSIS Misnomer; Basically it is Osteonecrosis (dead bone)
Also c/a Osteochondritis Dissecans Osteochondritis Dissecans / / Chandler’s DiseaseChandler’s Disease
in Young Adults
60% => B/L
One of the most challenging problems faced by orthopaedic surgeons.
Annual Incidence in US 15,000-20,000 Estimated Burden => 10% of total THR’s d/t AVN (50,000) 25% of total expenditure on AVN (1 billion $)
M/c affects => Femoral HeadFemoral Head
M/c site => Anterolateral aspectAnterolateral aspect (Being principal Wt. bearing portion)
Incidence d/t Steroid usage & Trauma
AVN only occurs in FATTY MARROWFATTY MARROW, which contains a Sparse vascular supplySparse vascular supply. In contrast to Hematopoietic marrow which has a rich blood supply
AVASCULAR NECROSISAVASCULAR NECROSIS
NO……………….NO……………….
Fat cells become smaller in elderly persons. The space between fat cells fills with a loose reticulum and mucoid fluid, which are resistant to AVN.
This condition is termed Gelatinous marrowGelatinous marrow.. Even in the presence of increased intramedullary pressure, interstitial fluid is
able to escape into the blood vessels, leaving the spaces free to absorb additional fluid.
Does Elderly Persons are at Does Elderly Persons are at
increased risk for AVNincreased risk for AVN?????????
ETIOLOGYETIOLOGY
IntravascularIntravascular
Extraosseous Extraosseous vascular factorvascular factor I. Arterial factors
Intraosseous Intraosseous vascular factorsvascular factors I. Arterial factors II. Venous factors
ExtravascularExtravascular
Intraosseous Intraosseous factorsfactors
Capsular factors
Extraosseous Vascular FactorsExtraosseous Vascular Factors Arterial FactorsArterial Factors
Most important
Femoral Head blood supply is an End-Organ SystemEnd-Organ System with poor collateral development
Trauma to the hip may l/t contusion or mechanical interruption to the Lateral Retinacular VesselsLateral Retinacular Vessels (main blood supply of the femoral head & neck)
Intraosseous Vascular FactorsIntraosseous Vascular Factors
Arterial FactorsArterial Factors
Circulating microemboliCirculating microemboli that block the microcirculation of the femoral head
In Conditions like-
1. Fat emboli (hyperlipidemia associated with alcoholism) 2. steroid therapy3. SCD4. nitrogen bubbles in decompression sickness
Enlargement of intramedullary fat cells or fat-loading osteocytes causes the cells to expand; this may be the most significant factor l/t obstruction of venous drainageobstruction of venous drainage
Reducing venous outflow & causing stasis
S/i Caisson disease & SCD
Intraosseous Vascular FactorsIntraosseous Vascular Factors
Venous FactorsVenous Factors
Ficat et alFicat et al demonstrated increased bone marrow demonstrated increased bone marrow pressure in the femoral necks of a large number pressure in the femoral necks of a large number of patients with avascular necrosis of the femoral of patients with avascular necrosis of the femoral head (AVN).head (AVN).
Extravascular FactorsExtravascular Factors
Intraosseous FactorsIntraosseous Factors
Alcohol & SteroidAlcohol & Steroid
Direct toxic metabolic Direct toxic metabolic effect on osteogenic cellseffect on osteogenic cells
Steroid Steroid
Hypertrophy of Fat cellsHypertrophy of Fat cellsGaucher cells & Inflammatory cells Gaucher cells & Inflammatory cells
Encroach on intraosseous capillaries Encroach on intraosseous capillaries
Intramedullary circulation Intramedullary circulation
Compartment syndromeCompartment syndrome
Trauma, Infection & ArthritisTrauma, Infection & Arthritis
Effusions within the Hip jointEffusions within the Hip joint
Intracapsular PressureIntracapsular Pressure
Tamponade of the LEVs Tamponade of the LEVs
Extravascular FactorsExtravascular Factors
Capsular FactorsCapsular Factors
SEQUELAE OF AVNSEQUELAE OF AVN
Minimal AVNMinimal AVN
Avascular area is Avascular area is small & is not adjacent small & is not adjacent to an articular surface.to an articular surface.
Patient may be Patient may be AsymptomaticAsymptomatic
Healing may occur Healing may occur spontaneously or the spontaneously or the disease may remain disease may remain undetected undetected
More Severe AVNMore Severe AVN
Once AVN develops, repair Once AVN develops, repair Begins at the interface b/w Begins at the interface b/w viable bone & necrotic bone viable bone & necrotic bone
Ineffective ResorptionIneffective Resorption of of dead bone within the necrotic dead bone within the necrotic focus is the rule. focus is the rule. Mixed sclerotic and cysticMixed sclerotic and cystic appearance on radiographs.appearance on radiographs.
MECHANICAL FAILUREMECHANICAL FAILURE
Non-healing Micro# in Non-healing Micro# in Subchondral regionSubchondral region
DDiffuse Subchondral #
X-Ray :- X-Ray :- CrescentCrescent
Progressive Wt. Bearing Progressive Wt. Bearing
Degenerative joint disease (DJD) & Joint DissolutionDegenerative joint disease (DJD) & Joint Dissolution
SEQUELAE OF AVNSEQUELAE OF AVN
Collapse of the Collapse of the Articular CartilageArticular Cartilage
Vicious CycleVicious Cycle
CAUSESCAUSES Trauma Trauma Alcohol consumptionAlcohol consumption Corticosteroid intakeCorticosteroid intake Hypercortisolism Cushing disease Hemoglobinopathies (SCD;Hb S/C;Polycythemia) Caisson disease
(Dysbaric osteonecrosis) Pancreatitis Neoplasms CRF Hemodialysis Cigarette smoking Collagen Vascular dis. SLE
Gout and hyperuricemia Hypercholesterolemia Hypercoagulable states Hyperlipidemia Hyperparathyroidism Intravascular coagulation Organ transplantation Pregnancy Congenital dislocation Hip Ehlers-Danlos synd Heredity dysostosis Legg-Calvé-Perthes dis Fabry disease Gaucher disease Giant cell arteritis Thrombophlebitis Idiopathic
Mechanism of Development of AVN d/t TraumaMechanism of Development of AVN d/t Trauma
Steroid (35-40%)Steroid (35-40%)
6 mechanisms 1. Fat Emboli from the liver => Occlusion of Small VesselsOcclusion of Small Vessels 2. Steroid Intramedullary Fat Cells Size without an equivalent
compensatory loss of trabecular & cortical bone => Intraosseous Intraosseous pressurepressure
3. Fat Emboli FFAs Toxic to vascular endo. Intravascular CoagulationIntravascular Coagulation
4. Synthesis of Polyclonal Antithyroid Hormone Receptor Alpha-Ab
Angiogenesis Proteolytic ActivityProteolytic Activity5. A direct toxic effect occurs on osteogenic cells6. Hematopoietic Marrow Fatty Marrow
> 20 mg & 6 Wks => Risk
CAUSESCAUSES
Hydrolysis
(-)
Steroid Induced Blood Flow
Investigations Investigations
MRIMRI SPECT SPECT CT ScanCT Scan Plain X-RayPlain X-Ray Most SensitiveMost Sensitive
1.5-T magnet1.5-T magnet 88% sensitivity 100% specificity
94% accuracy (Beltran et al)(Beltran et al)
Indispensable for Accurate StagingAccurate Staging
of AVN because images clearly depict1. Size of the lesion2. Gross estimates of
stage
Reflects Vascular IntegrityVascular Integrity
Avascular Focus may be demonstrated Early in Early in DiseaseDisease (MRI Contrast)(MRI Contrast)
85% sensitivity (Collier)(Collier)
Triple-Head High- resolution SPECT Sensitivity 97% (Lee et al)(Lee et al)
For Extent of InvolvementExtent of Involvement e.g. Subchondral Lucencies & Sclerosis during Reparative stage
Enables detection of subchondral or cancellous # & collapse
Unable to detect disease of stage 0 or 1
Helpful in assessing flattening flattening of the Femoral Head & asso.of the Femoral Head & asso. Degen. changes Degen. changes
Radiology- sequential Changes
• Crescent Sign• Osteoporosis• Sclerosis• Cystic changes• Loss of spherical weight bearing
dome• Partial collapse of head• Secondary Osteoarthritis
Classic Findings:-Classic Findings:- look for focal lesion in the look for focal lesion in the anterosuperior portion of femoral head that is well anterosuperior portion of femoral head that is well demarcated but is inhomogeneousdemarcated but is inhomogeneous
T1 imagesT1 images => low signal intensity => low signal intensity
T2 imagesT2 images => => double line sign =>double line sign => classic sign of AVN, classic sign of AVN, made up of 2 concentric low and high signal bandsmade up of 2 concentric low and high signal bands
high-signal-intensity line may represent hypervascular high-signal-intensity line may represent hypervascular granulation tissuegranulation tissue
MRI FindingsMRI Findings
MRI T1 image
signal from ischemic marrow
• Single band like area of low signal intensity.
• 100% sensitivity
• 98% specificity
Double Line sign – T2 image
• A second high signal intensity seen within the line seen on T1 images.
• Represent hyper vascular granulation tissue
Early
FEMORAL HEAD CHANGES
CORONAL T2-WEIGHTED MRI CORONAL T2-WEIGHTED MRI
Axial CT: Patient without AVN of the Femoral HeadAxial CT: Patient without AVN of the Femoral Head
Prominent & Thickened but Normal Trabeculae
ASTERISK SIGNASTERISK SIGN
TRANSIENT OSTEOPOROSIS OF THE HIP TRANSIENT OSTEOPOROSIS OF THE HIP (TOH) (TOH) D/D:-D/D:-
No findings of bone infarction or repair, which are the hallmarks of No findings of bone infarction or repair, which are the hallmarks of osteonecrosisosteonecrosis
The pathologic picture is primarily one of marrow edema, hence also The pathologic picture is primarily one of marrow edema, hence also referred to as referred to as Bone marrow edema syndrome (BMES) Bone marrow edema syndrome (BMES)
Clinically, pain is usually more sudden, severeClinically, pain is usually more sudden, severe
in females esp.during 3in females esp.during 3rdrd trimester of pregnancy trimester of pregnancy
Dx can be made readily based on MRI in most casesDx can be made readily based on MRI in most cases
TOH is usually self-limited.T/t is protected weight bearing to prevent #. TOH is usually self-limited.T/t is protected weight bearing to prevent #. Infrequently, core decompression may be indicated if a patient has an Infrequently, core decompression may be indicated if a patient has an inordinate amount of pain or if the diagnosis is in doubt.inordinate amount of pain or if the diagnosis is in doubt.
A diffuse low signal intensity in the T1-weighted image and a high intensity A diffuse low signal intensity in the T1-weighted image and a high intensity in the T2-weighted imagein the T2-weighted image
• In the 1960s, Arlet & Ficat in France
described a 3-part staging system & in the
1970s a 4th stage was added
CLASSIFICATION & STAGINGCLASSIFICATION & STAGING
Paul FICAT
This form is perhaps the one This form is perhaps the one most widely usedmost widely used now, despite the now, despite the fact that a stage 0 & a transitional stage were added laterfact that a stage 0 & a transitional stage were added later
FICAT’s scientific works spanned a wide range of topics from ligament instability to osteoarthrosis & from chondromalacia patellae to AVN
To each area he brought not only the perception of the clinician but also the ability to see with the eyes of the physiologist, the microscopist & even the electron microscopist
He was one of the few orthopedic clinicians with the ability to “see” problems at the cellular and subcellular level
Paul FICAT1917-19861917-1986
Stage Clinical Features Radiographs
0 Preclinical 0 0
1 Preradiographic + 0
2 Precollapse + Diffuse Porosis,
Sclerosis, Cysts
3 Early Collapse ++ Crescent Sign Certain Sequestrum,
Joint Space Normal
4 Osteoarthritis +++ Flattened Contour Decreased Joint Space Collapse of Head
Ficat & Arlet ClassificationFicat & Arlet Classificationt Stages of Bone Necrosis
A major disadvantage was that it A major disadvantage was that it didn’t include any measurement of didn’t include any measurement of
lesion size or articular surface lesion size or articular surface involvement..involvement..
Stage 1Stage 1 : Asymptomatic, mottled increased density of : Asymptomatic, mottled increased density of femoral headfemoral head
Stage 2Stage 2 : Asymptomatic , area of necrosis demarcated by a : Asymptomatic , area of necrosis demarcated by a rim of increased densityrim of increased density
Stage 3Stage 3 : Intermittent pains, : Intermittent pains, Crescent signCrescent sign in frog lateral in frog lateral viewview
Stage 4Stage 4 : Painful limb & flattening of femoral head : Painful limb & flattening of femoral head
Stage 5Stage 5 : Symptoms & signs of degenerative arthritis : Symptoms & signs of degenerative arthritis
Stage 6Stage 6 : Severe degenerative arthritis : Severe degenerative arthritis
Radiographic StagingRadiographic Staging(Marcus et al 1973)(Marcus et al 1973)
Stage 0 – 3Stage 0 – 3 :- Same as Ficat Arlet :- Same as Ficat Arlet Stage 4Stage 4 :- Flattening of femoral head :- Flattening of femoral head
Stage 5Stage 5 :- Joint narrowing with or without acetabular :- Joint narrowing with or without acetabular involvementinvolvement
Stage 6Stage 6 :- Advanced degenerative changes :- Advanced degenerative changes
These stages were further divided intoThese stages were further divided into Mild, Moderate & SevereMild, Moderate & Severe
Steinberg et al (1995) Modified Steinberg et al (1995) Modified Ficat & Arlet ClassificationFicat & Arlet Classification
1974, Kerboul et alKerboul et al noted that the results of osteotomies performed for osteonecrosis depended on both the location & the location & the extent of the lesionthe extent of the lesion
This latter was expressed in degrees after measuring the arc of
the articular surface involved as seen on both AP and lateral radiographs of the femoral head.
Similar observations were reported by Wagner and Zeiler , Wagner and Zeiler , Sugioka et al. and Koo and Kim Sugioka et al. and Koo and Kim
Kerboul:- combined necrotic angle – AP LAT
0 Normal or nondiagnostic x-ray, bone scan, and MRI0 Normal or nondiagnostic x-ray, bone scan, and MRI
I Normal x-ray; abnormal bone scan and/or MRII Normal x-ray; abnormal bone scan and/or MRI A. Mild (15% of femoral head affected)A. Mild (15% of femoral head affected) B. Moderate (15%–30%)B. Moderate (15%–30%) C. Severe (30%)C. Severe (30%)
II “Cystic” and sclerotic changes in femoral headII “Cystic” and sclerotic changes in femoral head A. Mild (15% of femoral head affected)A. Mild (15% of femoral head affected) B. Moderate (15%–30%)B. Moderate (15%–30%) C. Severe (30%)C. Severe (30%)
III Subchondral collapse (‘Crescent Sign’) without III Subchondral collapse (‘Crescent Sign’) without flatteningflattening
A. Mild (15% of articular surface)A. Mild (15% of articular surface) B. Moderate (15%–30%)B. Moderate (15%–30%) C. Severe (30%)C. Severe (30%)
University Of Pennsylvania University Of Pennsylvania Classification of OsteonecrosisClassification of Osteonecrosis
IV Flattening of femoral headIV Flattening of femoral head A. Mild (15% of surface and 2 mm depression)A. Mild (15% of surface and 2 mm depression) B. Moderate (15%–30% of surface or 2–4 mm depression)B. Moderate (15%–30% of surface or 2–4 mm depression) C. Severe (30% of surface or 4 mm depression)C. Severe (30% of surface or 4 mm depression) V Joint narrowing and/or acetabular changesV Joint narrowing and/or acetabular changes A. Mild (Average of femoral head involvement as determined in stage IV & A. Mild (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)estimated acetabular involvement) B. Moderate (Average of femoral head involvement as determined in stage B. Moderate (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)IV & estimated acetabular involvement) C. Severe (Average of femoral head involvement as determined in stage IV C. Severe (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)& estimated acetabular involvement)
VI Advanced degenerative changesVI Advanced degenerative changes
From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head: From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head: Results of core decompression and grafting with electrical stimulationResults of core decompression and grafting with electrical stimulation
University Of Pennsylvania University Of Pennsylvania Classification of OsteonecrosisClassification of Osteonecrosis
1991, The Committee on Nomenclature & Staging of the Association Research Circulation Osseous (ARCO) endorsed the staging system developed at the University of Pennsylvania in the early 1980s
1992, location of the lesion, as described in the Japanese system , was added
1993, stages III & IV were combined, as were stages V & VI
ClassClass T1T1 T2T2 DefinitionDefinition
AA Bright Intermediate Fat signal
BB Bright Bright Blood signal
CC Intermediate Bright Fluid or edema signal
DD Dark Dark Fibrosis signal
Mitchell’s MRI StagingMitchell’s MRI Staging
Specific CriteriaSpecific Criteria Collapse of femoral head
Subchondral radiolucent line
Anterolateral sequestrum
Bone scan showing a photopenic region surronded by area of increased density
Double band on T2-weighted image
Bone biopsy showing empty lacunae involving multiple adjacent trabeculae
Criteria For DiagnosisCriteria For Diagnosis(Current Concept JBJS Mont & Hungerford)(Current Concept JBJS Mont & Hungerford)
Non specific criteriaNon specific criteria Collapse of femoral head with narrowing of joint space
Mottled ,cystic & sclerotic pattern in head
MRI showing changes in bone marrow
Painful movements of hip with normal X ray
H/O of alcohol & steroid intake
Non specific but abnormal biopsy , edema /fibrois
PreservePreserve rather than Replacing Femoral Head & Cartilage
Early InterventionEarly Intervention has favorable impact on the disease prognosis irrespective of T/t modality used
AIM OF TREATMENTAIM OF TREATMENT
Indications:-Indications:-
Small, Asymptomatic lesionsSmall, Asymptomatic lesions
Lesion is so advanced that prophylactic measures Lesion is so advanced that prophylactic measures would be of little valuewould be of little value
When Sx is contraindicated or declinedWhen Sx is contraindicated or declined
Buying time until arthroplasty is neededBuying time until arthroplasty is needed
Medical ManagementMedical Management
PROTECTED WEIGHT BEARINGPROTECTED WEIGHT BEARING Protect the involved area from excessive stress by using some form of limited Protect the involved area from excessive stress by using some form of limited
weight bearing. weight bearing. Canes or even crutchesCanes or even crutches are frequently prescribed are frequently prescribed Don’t alter the natural course of the disorderDon’t alter the natural course of the disorder
INDICATIONS:-INDICATIONS:-
AlternativeAlternative to surgical management to surgical management Small, Asymptomatic lesionsSmall, Asymptomatic lesions low weight bearing area, such as the low weight bearing area, such as the medial aspectmedial aspect of the femoral head of the femoral head
Poor medical conditionPoor medical condition
Following certain types of surgical proceduresFollowing certain types of surgical procedures, such as core , such as core decompression, grafting, and osteotomies (used as an adjunct)decompression, grafting, and osteotomies (used as an adjunct)
Most important role :Most important role :relatively advanced stages of osteonecrosisrelatively advanced stages of osteonecrosis. . Cane or Crutches can diminish symptoms and improve function considerably Cane or Crutches can diminish symptoms and improve function considerably
until such time as a reconstructive procedure is indicateduntil such time as a reconstructive procedure is indicated
Glueck & colleaguesGlueck & colleagues => Incidence of => Incidence of osteonecrosis in association with certain osteonecrosis in association with certain Coagulopathies & HyperlipidmiasCoagulopathies & Hyperlipidmias
Stanozolol anabolic androgenic steroidStanozolol anabolic androgenic steroid potenial potenial means of treating AVN associated with means of treating AVN associated with Coagulopathies & HyperlipidemiasCoagulopathies & Hyperlipidemias
Motomura et alMotomura et al => Incidence of => Incidence of SSteroid-inducedteroid-induced osteonecrosis in rabbits using a combination of osteonecrosis in rabbits using a combination of Warfarin & Probucol (Lipid Lowering Agents)Warfarin & Probucol (Lipid Lowering Agents)
ENAXOPARINENAXOPARIN adminstered for adminstered for 12 weeks12 weeks was was found to prevent radiographic found to prevent radiographic Progression of Progression of Stage 1 and Stage 2 idiopathicStage 1 and Stage 2 idiopathic osteonecrosis of osteonecrosis of the femoral head at 2 year follow upthe femoral head at 2 year follow up
GauthierGauthier => 95%-100% of transplant patients => 95%-100% of transplant patients who were treated with who were treated with Calcium Channel Calcium Channel BlockersBlockers experienced complete relief of experienced complete relief of Bone Bone Pain SyndromePain Syndrome
I.V.I.V. ILIOPROST ILIOPROST, a Vasoactive Prostacyclin , a Vasoactive Prostacyclin analogue showed significant improvements in analogue showed significant improvements in patients with patients with Bone Marrow Edema Syndrome & Bone Marrow Edema Syndrome & OsteonecrosisOsteonecrosis
Oral NifedipineOral Nifedipine => Relief of bone pain reported => Relief of bone pain reported in a small series of patients with Osteonecrosisin a small series of patients with Osteonecrosis
AlendronateAlendronate :- In a prospective study of 100 hips with :- In a prospective study of 100 hips with osteonecrosis, osteonecrosis, Agarwal et alAgarwal et al reported that l/t significant reported that l/t significant improvement in Pain & Disability scoresimprovement in Pain & Disability scores
Marrow edema Marrow edema improvedimproved on MRI & plain films were unchanged on MRI & plain films were unchanged or progressed one gradeor progressed one grade
In a prospective randomized study of 40 patients with stage II In a prospective randomized study of 40 patients with stage II or III osteonecrosis & minimum 2-year follow-up, only 2 of 29 or III osteonecrosis & minimum 2-year follow-up, only 2 of 29 patients taking alendronate experienced collapse of the femoral patients taking alendronate experienced collapse of the femoral head, whereas 19 of 25 heads in the control group collapsed head, whereas 19 of 25 heads in the control group collapsed
BisphosphonatesBisphosphonates => reportedly causing => reportedly causing Osteonecrosis of the JawOsteonecrosis of the Jaw , so should be used , so should be used cautiouslycautiously
PuerarinPuerarin :- :- An extract of the kudzu vineAn extract of the kudzu vine , , is purported to is purported to Cholesterol, Platelet Aggregation & cause Vasodilation.Cholesterol, Platelet Aggregation & cause Vasodilation.
In a study of Alcohol-induced Osteonecrosis in mice, puerarin In a study of Alcohol-induced Osteonecrosis in mice, puerarin was reported to lower serum cholesterol & to prevent the was reported to lower serum cholesterol & to prevent the changes of osteonecrosis in femoral heads.changes of osteonecrosis in femoral heads.
No data on the use of puerarin for osteonecrosis in humans No data on the use of puerarin for osteonecrosis in humans are availableare available
Pulsed Electromagnetic Field stimulationPulsed Electromagnetic Field stimulation, is , is reported to be useful for treatment of reported to be useful for treatment of osteonecrosis in 4 reports. osteonecrosis in 4 reports.
Mechanisms Of Action:-Mechanisms Of Action:-
1.1. Local control of inflammationLocal control of inflammation
2.2. Enhances repair activity & healing process by Enhances repair activity & healing process by stimulating neovascularisation & new bone stimulating neovascularisation & new bone formation.formation.
Electric, Electromagnetic & Acoustic T/t
Radiographic progression in Ficat stage II . Hips treated with core decompression (CD) plus pulsed electromagnet fields (PEMF) exhibit 33% less radiographic
progression than hips treated with CD alone (P 0.04)
There are only 2 papers in PubmedThere are only 2 papers in Pubmed
The only study is by The only study is by Wang et alWang et al who compared the who compared the results of such therapy in 23 patients (29 hips) with the results of such therapy in 23 patients (29 hips) with the results in a group treated with non-vascularized fibular results in a group treated with non-vascularized fibular graftinggrafting
At a mean of 25 months, At a mean of 25 months, 79%79% of the shock-wave group of the shock-wave group
had improved had improved Harris Hip ScoresHarris Hip Scores compared with compared with 29%29% of of the group treated with non-vascularized fibular graftingthe group treated with non-vascularized fibular grafting
Extracorporeal Shockwave TherapyExtracorporeal Shockwave Therapy
HBO improves oxygenation, reduces oedema & induces HBO improves oxygenation, reduces oedema & induces angioneogenesis, a reduction in intra osseous pressure angioneogenesis, a reduction in intra osseous pressure & improvement in microcirculation& improvement in microcirculation
Reis et alReis et al, 24 involving 16 hips in 12 patients, all with , 24 involving 16 hips in 12 patients, all with Steinberg Stage 1 disease, gave each patient 100 Steinberg Stage 1 disease, gave each patient 100 consecutive days of HBO, which involved breathing consecutive days of HBO, which involved breathing 100% oxygen via a maskat 2-2.4 atmospheres pressure 100% oxygen via a maskat 2-2.4 atmospheres pressure for 90 minutes for 90 minutes
They reported that They reported that 13 of the 1613 of the 16 femoral heads femoral heads subsequently appeared normal on MRI after this T/tsubsequently appeared normal on MRI after this T/t
Hyperbaric oxygen (HBO)Hyperbaric oxygen (HBO)
Supplemented with Core DecompressionSupplemented with Core Decompression
Principle:-Principle:-
The small no. of progenitor cells in the proximal extremity The small no. of progenitor cells in the proximal extremity of the femur with osteonecrosis of the femoral head of the femur with osteonecrosis of the femoral head causes insufficient creeping substitution after causes insufficient creeping substitution after osteonecrosisosteonecrosis
Red Bone Marrow Graft contains Osteogenic Red Bone Marrow Graft contains Osteogenic Precursors,which repopulate the osteonecrotic bonePrecursors,which repopulate the osteonecrotic bone
Bone Marrow InjectionsBone Marrow Injections
Bone Marrow InjectionsBone Marrow InjectionsTechniqueTechnique
Usual site => Usual site => Anterior Iliac CrestAnterior Iliac Crest
A beveled metal trocar of 6 to 8 cm A beveled metal trocar of 6 to 8 cm length & a bore of 1.5 mm is length & a bore of 1.5 mm is pushed deep into the cancellous pushed deep into the cancellous bone bone
Marrow is aspirated with A 10 ml Marrow is aspirated with A 10 ml syringe(flushed with heparin) syringe(flushed with heparin)
Aspirates pooled in plastic bags Aspirates pooled in plastic bags containing an anticoagulant containing an anticoagulant solutionsolution
Filtered to remove fat aggregates & Filtered to remove fat aggregates & clotsclots
Trocar
Current Indications:-Current Indications:-
The best indications are hips The best indications are hips with osteonecrosis & with osteonecrosis & without collapsewithout collapse
In some patients who had Steinberg stage III In some patients who had Steinberg stage III
(subchondral crescent, no collapse), successful (subchondral crescent, no collapse), successful outcomes (no further surgery) have been obtained outcomes (no further surgery) have been obtained between 5 and 10 years. Therefore, between 5 and 10 years. Therefore, in selected in selected patients, even more advanced diseasepatients, even more advanced disease can be can be considered for core decompressionconsidered for core decompression
Bone Marrow InjectionsBone Marrow Injections
Bone Marrow InjectionsBone Marrow Injections
Surgical proceduresSurgical procedures
Joint PreservingJoint Preserving Joint ReplacingJoint Replacing Core Core Decompression Decompression
Various Various Nonvascularized & Nonvascularized & Vascularized Bone Vascularized Bone Grafting ProceduresGrafting Procedures
Osteotomy Osteotomy ProceduresProcedures
Total Hip Total Hip Arthroplasty Arthroplasty
Hip Resurfacing Hip Resurfacing ProceduresProcedures
Core DecompressionCore Decompression
Core Core decompression decompression was “discovered” was “discovered” by Paul Ficat & by Paul Ficat & Jacques Arlet in Jacques Arlet in the 1960sthe 1960s
Incidental Incidental discoverydiscovery
Indications:-Indications:-
Core decompression is effective for symptomatic relief in Core decompression is effective for symptomatic relief in nearly all stages in all patients who present with a nearly all stages in all patients who present with a painful painful hip secondary to ONhip secondary to ON d/t of intramedullary pressure done d/t of intramedullary pressure done by itby it
Transient symptomatic relief in an advanced stage & in Transient symptomatic relief in an advanced stage & in already collapsing or when collapse is impendingalready collapsing or when collapse is impending
It is Most Effective in It is Most Effective in Stage I & IIStage I & II lesions that are lesions that are size Asize A (15% of head affected) (15% of head affected) & B& B (15%–30% of head affected) (15%–30% of head affected)
The larger the lesion, the less likely the patient is to have a The larger the lesion, the less likely the patient is to have a
successful outcome. successful outcome.
Core DecompressionCore Decompression
Standard Technique & its Variations:-Standard Technique & its Variations:- Ficat & ArletFicat & Arlet proposed creating an proposed creating an 8 to 10 mm dia core 8 to 10 mm dia core
tracktrack & this became a & this became a “standard” “standard”
Recently some authors have suggested that the same effect Recently some authors have suggested that the same effect of standard core can be achieved by producing of standard core can be achieved by producing Multiple Multiple Smaller Core Tracks of 3-mm diaSmaller Core Tracks of 3-mm dia range. This can be done range. This can be done percutaneously & theoretically # risk & shortens the percutaneously & theoretically # risk & shortens the operative time & morbidityoperative time & morbidity
Steinberg et alSteinberg et al proposed making proposed making Smaller Angled Core Smaller Angled Core Tracks into the Necrotic Segment from the Central Core Tracks into the Necrotic Segment from the Central Core CanalCanal
Core DecompressionCore Decompression
Postoperative ManagementPostoperative Management
The lateral cortical window produces a stress riser in the The lateral cortical window produces a stress riser in the proximal femur So proximal femur So Protect the patient from Protect the patient from unprotected weightbearingunprotected weightbearing for the first 6 weeks for the first 6 weeks
Reported incidence of # with core decompression is <1% Reported incidence of # with core decompression is <1% & has almost always been associated with either a fall or & has almost always been associated with either a fall or failure to use protective devices (crutches or a walker) in failure to use protective devices (crutches or a walker) in the first 6 weeksthe first 6 weeks
Core DecompressionCore Decompression
Bone grafting procedures are a group of joint preserving Bone grafting procedures are a group of joint preserving techniques that involve the removal of the diseased femoral techniques that involve the removal of the diseased femoral head segment, f/b its replacement with 1or more of a variety of head segment, f/b its replacement with 1or more of a variety of bone graft optionsbone graft options
These are most valuable in treating patients with These are most valuable in treating patients with Stage I & II Stage I & II diseasedisease
Bone Grafting ProceduresBone Grafting Procedures
Techniques:-Techniques:-
Grafting Through Lateral Core Track
Grafting Through Femoral Neck Window
Grafting Through Articular Surface Window
Bone Grafting ProceduresBone Grafting Procedures
Grafting Through Lateral Core TrackGrafting Through Lateral Core Track
Advantages:-Advantages:-
Simple technique Minimal Invasiveness Avoidance of surgical dislocation of the hip Low Complication Rate Can be performed bilaterally under one anesthetic
Disadvantages:-Disadvantages:-
Inability to directly visualize the joint surfaces Inexact nature of removing diseased bone & replacing it
with bone graft under fluoroscopic guidance Risk of postoperative #
Grafting Through Lateral Core TrackGrafting Through Lateral Core Track
Watson-Jones or Smith-Peterson approach Watson-Jones or Smith-Peterson approach is used is used
A window is created to expose the anterior A window is created to expose the anterior femoral neck, at the level of the junction of femoral neck, at the level of the junction of the femoral head & neck the femoral head & neck
When Combined with a Bone Grafting When Combined with a Bone Grafting procedure,refered as the procedure,refered as the “light bulb” “light bulb” procedure.procedure.
AdvantageAdvantage is the improved access to the is the improved access to the
necrotic femoral head segment & the necrotic femoral head segment & the avoidance of direct iatrogenic cartilage avoidance of direct iatrogenic cartilage damagedamage
DisadvantageDisadvantage is the creation of a cortical is the creation of a cortical defect in the femoral neck, which raises the defect in the femoral neck, which raises the risk of fracturerisk of fracture
Grafting Through Femoral Neck WindowGrafting Through Femoral Neck Window
The 3The 3rdrd method of accessing the necrotic segment of the femoral head is method of accessing the necrotic segment of the femoral head is known as the known as the “Trapdoor” approach“Trapdoor” approach
With this method, the hip is surgically dislocated using a technique aimed at With this method, the hip is surgically dislocated using a technique aimed at preserving the blood supply to the femoral head & neckpreserving the blood supply to the femoral head & neck
Once exposed, a “trapdoor” window is made in the femoral head cartilage Once exposed, a “trapdoor” window is made in the femoral head cartilage to access the diseased subchondral bone to access the diseased subchondral bone
When combined with a bone grafting procedure, refered as the When combined with a bone grafting procedure, refered as the “Trapdoor” “Trapdoor” Procedure Procedure
AdvantageAdvantage : Exposure allows a direct evaluation of the cartilage surface & : Exposure allows a direct evaluation of the cartilage surface &
underlying diseased femoral head segment & allows for underlying diseased femoral head segment & allows for precise bone graft placement. precise bone graft placement.
DisadvantageDisadvantage : Demanding technical nature : Demanding technical nature Iatrogenic cartilage damage & osteonecrosisIatrogenic cartilage damage & osteonecrosis Surgical dislocationSurgical dislocation
Grafting Through Articular SurfaceWindowGrafting Through Articular SurfaceWindow
Grafting Through Articular SurfaceWindowGrafting Through Articular SurfaceWindow
Nonvascularized GraftsNonvascularized Grafts Nonvascularized cortical Nonvascularized cortical
bone graftsbone grafts are typically are typically prepared as several struts prepared as several struts that provide structural that provide structural support under the articular support under the articular surface within the evacuated surface within the evacuated segmentsegment
This construct is often This construct is often augmented with cancellous augmented with cancellous bone graft in an effort to bone graft in an effort to improve its osteoconductive improve its osteoconductive and/or osteoinductive and/or osteoinductive propertiesproperties
Vascularized GraftsVascularized Grafts
1.1. Local pedicled grafts,which Local pedicled grafts,which do not require microvascular do not require microvascular reanastomosisreanastomosis
eg :eg :Muscle-pedicle bone grafts Muscle-pedicle bone grafts Vascularized pedicle bone Vascularized pedicle bone
graftsgrafts
2.2. Free vascularized grafts, Free vascularized grafts, which require a which require a microvascular microvascular reanastomosis.reanastomosis.
eg: eg: Free vascularized fibula Free vascularized fibula graftgraft
Types of Bone GraftsTypes of Bone Grafts
Muscle-Pedicle Bone GraftsMuscle-Pedicle Bone Grafts
Baksi et alBaksi et al (1991) (1991) => results in treating 68 hips => results in treating 68 hips with a variety of muscle-pedicle bone graftswith a variety of muscle-pedicle bone grafts
The preferred techniques were the The preferred techniques were the tensor fascia tensor fascia lata-iliac crest graft anteriorly & the quadratus lata-iliac crest graft anteriorly & the quadratus femoris posteriorly. femoris posteriorly.
Of note, 82% of the hips treated in the series Of note, 82% of the hips treated in the series demonstrated some degree of collapsedemonstrated some degree of collapse
At a mean follow-up of 7 years, there were good At a mean follow-up of 7 years, there were good to excellent results in 83% of casesto excellent results in 83% of cases
Muscle-Pedicle Bone GraftsMuscle-Pedicle Bone Grafts
The harvested fibula with marbleized muscle attached confirming an extraperiosteal dissection. The peroneal artery & two accompanying veins
The main rationale proposed for the efficacy of The main rationale proposed for the efficacy of osteotomies is theosteotomies is the biomechanical effect of biomechanical effect of moving the collapsed/necrotic segment of the moving the collapsed/necrotic segment of the femoral head from the principal weight-bearing femoral head from the principal weight-bearing area of the hip to an area that bears less/no area of the hip to an area that bears less/no direct weight and to allow weight-bearing contact direct weight and to allow weight-bearing contact to now happen in an area of relatively normal to now happen in an area of relatively normal bone and cartilagebone and cartilage
Proximal Femoral OsteotomiesProximal Femoral Osteotomies
Categories:-Categories:-
Valgus or varus osteotomies usually Valgus or varus osteotomies usually combined with flexion or extensioncombined with flexion or extension
Transtrochanteric rotational osteotomiesTranstrochanteric rotational osteotomies
Proximal Femoral OsteotomiesProximal Femoral Osteotomies
Indications:-Indications:-
For varus or valgus osteotomies depend For varus or valgus osteotomies depend
on the location & size of the lesionon the location & size of the lesion
Osteotomies may be used for both Osteotomies may be used for both precollapse & postcollapse without notable precollapse & postcollapse without notable acetabular involvementacetabular involvement
Proximal Femoral OsteotomiesProximal Femoral Osteotomies
VALGUS OSTEOTOMY WITH FLEXION
• when the necrotic segment is located in the anterosuperior part of the femoral head with less than 20% posterior involvement.
• Optimal patient population would be those that are less than 45 years of age and are
not on steroids or chemotherapy
VALGUS OSTEOTOMY WITH FLEXION ANDVALGUS OSTEOTOMY WITH FLEXION ANDBONE GRAFTINGBONE GRAFTING
VARUS OSTEOTOMY WITH FLEXION OR VARUS OSTEOTOMY WITH FLEXION OR EXTENSIONEXTENSION
ROTATIONAL OSTEOTOMIES
• Sugioka first reported a transtrochanteric transposition osteotomy with anterior rotation of the head and neck of
the femur
Transposition of the necrotic focus to the ant. & inf. part of the femoral head away from the weight-bearing area as a result of the ant. rotation of the head
before rotationAfter rotation
ROTATIONAL OSTEOTOMYROTATIONAL OSTEOTOMY
ROTATIONAL OSTEOTOMYROTATIONAL OSTEOTOMY
Femoral & Acetabular Surface Replacement & Hemi-Femoral & Acetabular Surface Replacement & Hemi-Surface Replacement for Osteonecrosis of the HipSurface Replacement for Osteonecrosis of the Hip
Indications :-Indications :-
Later stages of osteonecrosis (University of Pennsylvania Later stages of osteonecrosis (University of Pennsylvania Stage III–VI)Stage III–VI)
> 30% femoral head involvement> 30% femoral head involvement
Hip Resurfacing ProceduresHip Resurfacing Procedures
Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971)Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971) independently were the first to perform metal-on polyethylene independently were the first to perform metal-on polyethylene resurfacingresurfacing
TownleyTownley introduced a total articular resurfacing arthroplasty introduced a total articular resurfacing arthroplasty (TARA; Depuy, Warsaw,IN) that resurfaced the femoral head (TARA; Depuy, Warsaw,IN) that resurfaced the femoral head with a metal component while replacing the articulating surface with a metal component while replacing the articulating surface of the acetabulum with a thin, plastic shell inserted with cementof the acetabulum with a thin, plastic shell inserted with cement
Metal-on-polyethylene resurfacing yieldedMetal-on-polyethylene resurfacing yielded unacceptably high failure rates. The unacceptably high failure rates. The polyethylene-induced osteolysis resultingpolyethylene-induced osteolysis resulting from the mating of large metal femoral from the mating of large metal femoral head components with thin diameter head components with thin diameter acetabular cupsacetabular cups
Metal-on Polyethylene ResurfacingMetal-on Polyethylene Resurfacing
Reduces the Reduces the incidence of long-term incidence of long-term failure from aseptic failure from aseptic loosening & loosening & osteolysisosteolysis
Metal-on-Metal BearingsMetal-on-Metal Bearings
TOC for advanced osteonecrosis of the hip (University of TOC for advanced osteonecrosis of the hip (University of Pennsylvania Stages IVB–VIC)Pennsylvania Stages IVB–VIC)
Excellent pain relief & functional improvementsExcellent pain relief & functional improvements
More recent studies at intermediate follow up up to 10 More recent studies at intermediate follow up up to 10 years have demonstrated similar survivorship compared years have demonstrated similar survivorship compared to total hip replacement for osteoarthrosis.to total hip replacement for osteoarthrosis.
Total Hip ReplacementTotal Hip Replacement
Bhumika – Non Cemented THR
FEMORAL ENDOPROSTHESISFEMORAL ENDOPROSTHESIS
ARTHRODESISARTHRODESIS
RESECTION ARTHROPLASTYRESECTION ARTHROPLASTY
ACRYLIC CEMENT INJECTIONACRYLIC CEMENT INJECTION
Miscllaneous ProceduresMiscllaneous Procedures
Initial changes are in the Initial changes are in the femoral head and not the femoral head and not the acetabulumacetabulum
Replacing the femoral Replacing the femoral head would also be more head would also be more conservative than the conservative than the additive procedure of additive procedure of acetabular reconstruction, acetabular reconstruction, allowing for later simple allowing for later simple conversion to total hip conversion to total hip arthroplastyarthroplasty
Femoral EndoprosthesisFemoral Endoprosthesis
Mostly a salvage procedure in contemporary orthopedicsMostly a salvage procedure in contemporary orthopedics
In the patient with significant pain & disability & in whom In the patient with significant pain & disability & in whom nonsurgical T/t has failed with a contraindication to nonsurgical T/t has failed with a contraindication to prosthetic replacement prosthetic replacement
Clinical success can be achieved as it may relieve hip painClinical success can be achieved as it may relieve hip pain
The recommended position is 0° to 5° of adduction, 25° to The recommended position is 0° to 5° of adduction, 25° to 30° of flexion & 0° to 15° of external rotation30° of flexion & 0° to 15° of external rotation
Later revision to a THR has a significant complication Later revision to a THR has a significant complication rate with less functional outcomerate with less functional outcome
Arthrodesis Arthrodesis
T/t of last resortT/t of last resort
Complete resection of the head & neck of the femurComplete resection of the head & neck of the femur Can achieve a good range of pain-free motion & will be able to Can achieve a good range of pain-free motion & will be able to
function reasonably well for most activities of daily livingfunction reasonably well for most activities of daily living
The use of a shoe lift is generally necessary as a result of the The use of a shoe lift is generally necessary as a result of the shortening of the extremity, which averages approximately shortening of the extremity, which averages approximately 1.5 1.5 inchesinches
There will be a noticeable There will be a noticeable abductor lurchabductor lurch & patients will & patients will require some form of assistive device for ambulationrequire some form of assistive device for ambulation
Indication:-Indication:- patient with severe pain and disability who is not a patient with severe pain and disability who is not a
suitable candidate for reconstructionsuitable candidate for reconstruction
Resection ArthroplastyResection Arthroplasty
Debriding the necrotic zone then elevating & supporting the Debriding the necrotic zone then elevating & supporting the collapsed segment by the injection of cementcollapsed segment by the injection of cement
Wood and coworkersWood and coworkers reported on very preliminary results 21 reported on very preliminary results 21 of 20 casesof 20 cases
All patients realized immediate pain relief with improved hip All patients realized immediate pain relief with improved hip scores, with 3 patients undergoing early conversion to total hip scores, with 3 patients undergoing early conversion to total hip arthroplastyarthroplasty
Relatively invasive but may have the advantage of maintaining Relatively invasive but may have the advantage of maintaining femoral head congruityfemoral head congruity
Long-term results with perhaps a randomized controlled series Long-term results with perhaps a randomized controlled series will be necessary if this is a viable alternative to reconstructive will be necessary if this is a viable alternative to reconstructive surgerysurgery
Acrylic Cement InjectionAcrylic Cement Injection
POROUS TANTALUM ROD INSERTIONPOROUS TANTALUM ROD INSERTION
A novel approach in T/t of stage I & II precollapse osteonecrosisA novel approach in T/t of stage I & II precollapse osteonecrosis
This rod functions analogously to a This rod functions analogously to a Cortical Strut GraftCortical Strut Graft allowing allowing structural & osteoconductive propertiesstructural & osteoconductive properties
POROUS TANTALUM ROD INSERTIONPOROUS TANTALUM ROD INSERTION
““Young medical men find it so much easier to speculate then to observe. Young medical men find it so much easier to speculate then to observe. Nothing is known to our profession by guess. There is no short road to Nothing is known to our profession by guess. There is no short road to
knowledge. Observations on diseased living, examinations of the dead & knowledge. Observations on diseased living, examinations of the dead & experiments upon living animals are the only sources of true experiments upon living animals are the only sources of true
knowledgeknowledge.”.”
Sir Astley Paston COOPERSir Astley Paston COOPER 1768–18411768–1841
Thank you