SlideShare une entreprise Scribd logo
1  sur  115
Télécharger pour lire hors ligne
AVASCULAR NECROSIS
   FEMORAL HEAD

         By :
   Dr. Rajat Malot
 Assistant Professor
SMS Medical college
        Jaipur
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 Lateral pain or              Posterior hip pain
Groin pain           Trochanteric pain


Rule out: hip             Rule out: hip           Rule out: sciatic
fracture, septic joint,   fracture, bone tumor,   nerve irritation
and avascular             referred pain from      ,sacroiliitis due to
necrosis                  lumbar disc             spondyloarthropathy,
                          herniation              lumbardisc or facet
                                                  disease
Other causes:OA,          Other causes:
RA,                       trochanteric
iliopectineal bursitis    bursitis,OA, radiating Other causes:muscle
                          from                   strain
                          lumbar disc or facet
                          disease
CLINICAL PRESENTATION

 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
Characteristics Of Pain
 Focal over the groin / hip or it may radiate to the buttocks,
  anteromedial thigh or knee

 Induced mechanically by standing & walking & may be eased
  by rest

 May be very intense, throbbing, deep & often intermittent

 Worsened by coughing & at night

 40% of patients have night pain asso. with morning stiffness

 A Click may be heard when the patient rises from a sitting
  position or on external rotation of an abducted hip
Range Of Motion
 ROM may be diminished, especially after collapse of the
  femoral head

 ROM may be limited, especially in flexion, abduction & internal
  rotation

 Gait :- Patients may walk with a limp.

 The Trendelenburg sign may be Positive

 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
BLOOD SUPPLY OF FEMORAL HEAD
 The principal sources are the Lateral Epiphyseal Vessels
  (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) supplies
  medial third of the femoral head.

 Branches of LEVs & ALT anastomose at the junction of central
  & medial 1/3 of the femoral head
lateral circumflex A.




        Medial circumflex A.




           BLOOD SUPPLY OF FEMORAL HEAD
Blood Supply in Paediatric Age Gp.
  Till 4-7 years of age, the vascular anatomy in a
                     age
   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 HISTORY
 Konig (1888) => first described the condition coined the
  term Osteochondritis Dissecans

 Haenish (1925) => first case of idiopathic ischemic
  necrosis of the femoral head in an adult

 Arterial Occlusion (1940) was postulated as the cause of
  the necrosis.

 Pietrograndi (1957) => AVN d/t Steroid therapy
AVASCULAR NECROSIS
 Misnomer; Basically it is Osteonecrosis (dead bone)

 Also c/a Osteochondritis Dissecans / Chandler’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 $)
AVASCULAR NECROSIS
 M/c affects => Femoral Head

 M/c site => Anterolateral aspect (Being principal Wt.
  bearing portion)

 Incidence d/t Steroid usage & Trauma

 AVN only occurs in FATTY MARROW, which contains
                             MARROW
  a Sparse vascular supply. In contrast to Hematopoietic
                    supply
  marrow which has a rich blood supply
Does Elderly Persons are at
                              increased risk for AVN?????
                                                 AVN



                                  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 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.
ETIOLOGY
Intravascular              Extravascular

Extraosseous               Intraosseous
vascular factor              factors
     I. Arterial factors

                            Capsular factors
Intraosseous
vascular factors
     I. Arterial factors
     II. Venous factors
Extraosseous Vascular Factors

Arterial Factors
  Most important


  Femoral Head blood supply is an End-Organ System
   with poor collateral development




  Trauma to the hip may l/t contusion or mechanical
   interruption to the Lateral Retinacular Vessels (main
   blood supply of the femoral head & neck)
Intraosseous Vascular Factors

Arterial Factors
     Circulating microemboli that block the
      microcirculation of the femoral head

     In Conditions like-

 6.   Fat emboli (hyperlipidemia associated with alcoholism)
 7.   steroid therapy
 8.   SCD
 9.   nitrogen bubbles in decompression sickness
Intraosseous Vascular Factors

Venous Factors

  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 drainage




          Reducing venous outflow & causing stasis


  S/i Caisson disease & SCD
Extravascular Factors

Intraosseous Factors
  Ficat et al demonstrated increased bone marrow
   pressure in the femoral necks of a large number
   of patients with avascular necrosis of the femoral
   head (AVN).
               Steroid                      Alcohol & Steroid

      Hypertrophy of Fat cells
 Gaucher cells & Inflammatory cells

 Encroach on intraosseous capillaries
                                          Direct toxic metabolic
       Intramedullary circulation       effect on osteogenic cells

       Compartment syndrome
Extravascular Factors

Capsular Factors
          Trauma, Infection & Arthritis

           Effusions within the Hip joint

              Intracapsular Pressure

             Tamponade of the LEVs
SEQUELAE OF AVN
Minimal AVN                 More Severe AVN

 Avascular area is small    Once AVN develops, repair
  & is not adjacent to an     Begins at the interface b/w
  articular surface.          viable bone & necrotic bone
 Patient may be
  Asymptomatic
                             Ineffective Resorption of
 Healing may occur          dead bone within the necrotic
  spontaneously or the       focus is the rule.
  disease may remain         Mixed sclerotic and cystic
  undetected                 appearance on radiographs.
SEQUELAE OF AVN
                 MECHANICAL FAILURE

         Non-healing Micro# in Subchondral region



Collapse of the     Vicious Cycle   Diffuse Subchondral #
Articular Cartilage                  X-Ray :- Crescent


                  Progressive Wt. Bearing

    Degenerative joint disease (DJD) & Joint Dissolution
CAUSES
 Trauma                         Gout and hyperuricemia
 Alcohol consumption            Hypercholesterolemia
 Corticosteroid intake          Hypercoagulable states
 Hypercortisolism               Hyperlipidemia
 Cushing disease                Hyperparathyroidism
 Hemoglobinopathies             Intravascular coagulation
 (SCD;Hb S/C;Polycythemia)       Organ transplantation
 Caisson disease                Pregnancy
   (Dysbaric osteonecrosis)      Congenital dislocation Hip
 Pancreatitis                   Ehlers-Danlos synd
 Neoplasms                      Heredity dysostosis
 CRF                            Legg-Calvé-Perthes dis
 Hemodialysis                   Fabry disease
 Cigarette smoking              Gaucher disease
 Collagen Vascular dis.       Giant cell arteritis
 SLE                          Thrombophlebitis
                               Idiopathic
Mechanism of Development of AVN d/t Trauma
CAUSES
Steroid (35-40%)
 6 mechanisms

•   Fat Emboli from the liver => Occlusion of Small Vessels
•   Steroid     Intramedullary Fat Cells Size without an equivalent
    compensatory loss of trabecular & cortical bone => Intraosseous
    pressure
•   Fat Emboli Hydrolysis FFAs          Toxic to vascular endo.
    Intravascular Coagulation
•   Synthesis of Polyclonal Antithyroid Hormone Receptor Alpha-Ab
     (-)
         Angiogenesis           Proteolytic Activity
10.A direct toxic effect occursSteroid Induced Blood Flow
                                on osteogenic cells
11.Hematopoietic Marrow                                     Fatty Marrow

 > 20 mg & 6 Wks =>            Risk
Investigations
       MRI                SPECT                 CT Scan             Plain X-Ray
   Most Sensitive      Reflects Vascular Integrity
                                                        Unable to detect disease of
    1.5-T magnet       Avascular Focus may be         stage 0 or 1
     88% sensitivity    demonstrated Early in
    100% specificity    Disease (MRI Contrast)          Helpful in assessing flattening
                                                        of the Femoral Head & asso.
     94% accuracy       85% sensitivity                Degen. changes
    (Beltran et al)     (Collier)
                                         For Extent of Involvement
 Indispensable for  Triple-Head High-  e.g. Subchondral Lucencies
    Accurate Staging resolution SPECT    & Sclerosis during Reparative stage
   of AVN because       Sensitivity 97%
  images clearly depict (Lee et al)      Enables detection of subchondral or
12. Size of the lesion                   cancellous # & collapse
13. Gross estimates of
Radiology- sequential
      Changes
• Crescent Sign
• Osteoporosis
• Sclerosis
• Cystic changes
• Loss of spherical weight
  bearing dome
• Partial collapse of head
• Secondary Osteoarthritis
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
MRI Findings
 Classic Findings:- look for focal lesion in the
  anterosuperior portion of femoral head that is well
  demarcated but is inhomogeneous

 T1 images => low signal intensity

 T2 images => double line sign => classic sign of AVN,
  made up of 2 concentric low and high signal bands

 high-signal-intensity line may represent hypervascular
  granulation tissue
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
Prominent & Thickened
                                 but Normal Trabeculae




             ASTERISK SIGN


Axial CT: Patient without AVN of the Femoral Head
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
TRANSIENT OSTEOPOROSIS OF THE HIP
               (TOH)
    D/D:-

 No findings of bone infarction or repair, which are the hallmarks of
  osteonecrosis
 The pathologic picture is primarily one of marrow edema, hence also
  referred to as Bone marrow edema syndrome (BMES)

 Clinically, pain is usually more sudden, severe

    in females esp.during 3rd trimester of pregnancy

 Dx can be made readily based on MRI in most cases

 TOH is usually self-limited.T/t is protected weight bearing to prevent #.
  Infrequently, core decompression may be indicated if a patient has an
  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
  in the T2-weighted image
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
CLASSIFICATION & STAGING
   • In the 1960s, Arlet & Ficat in France
   described a 3-part staging system & in the
   1970s a 4th stage was added
                                                        Paul FICAT




This form is perhaps the one most widely used now, despite the

 fact that a stage 0 & a transitional stage were added later
Paul FICAT
                                1917-1986

 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
Ficat & Arlet Classification
              t Stages of Bone Necrosis
   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
A major disadvantage was that it didn’t include any
  measurement of lesion size or articular surface
                  involvement..
Radiographic Staging
                  (Marcus et al 1973)
 Stage 1 : Asymptomatic, mottled increased density of
            femoral head

 Stage 2 : Asymptomatic , area of necrosis demarcated by a
            rim of increased density

 Stage 3 : Intermittent pains, Crescent sign in frog lateral
  view

 Stage 4 : Painful limb & flattening of femoral head

 Stage 5 : Symptoms & signs of degenerative arthritis

 Stage 6 : Severe degenerative arthritis
Steinberg et al (1995) Modified
  Ficat & Arlet Classification
Stage 0 – 3 :- Same as Ficat Arlet

Stage 4 :- Flattening of femoral head

Stage 5 :- Joint narrowing with or without acetabular
           involvement

Stage 6 :- Advanced degenerative changes


          These stages were further divided into
               Mild, Moderate & Severe
 1974, Kerboul et al noted that the results of osteotomies
  performed for osteonecrosis depended on both the location &
  the 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 ,
  Sugioka et al. and Koo and Kim
Kerboul:- combined necrotic angle –
          AP          LAT
University Of Pennsylvania
  Classification of Osteonecrosis
 0 Normal or nondiagnostic x-ray, bone scan, and MRI

 I Normal x-ray; abnormal bone scan and/or MRI
  A. Mild (15% of femoral head affected)
  B. Moderate (15%–30%)
  C. Severe (30%)

 II “Cystic” and sclerotic changes in femoral head
  A. Mild (15% of femoral head affected)
  B. Moderate (15%–30%)
  C. Severe (30%)


 III Subchondral collapse (‘Crescent Sign’) without
  flattening
  A. Mild (15% of articular surface)
  B. Moderate (15%–30%)
  C. Severe (30%)
University Of Pennsylvania
  Classification of Osteonecrosis
 IV Flattening of femoral head
  A. Mild (15% of surface and 2 mm depression)
  B. Moderate (15%–30% of surface or 2–4 mm depression)
  C. Severe (30% of surface or 4 mm depression)

 V Joint narrowing and/or acetabular changes
   A. Mild (Average of femoral head involvement as determined in stage IV &
           estimated acetabular involvement)
   B. Moderate (Average of femoral head involvement as determined in stage
                IV & estimated acetabular involvement)
   C. Severe (Average of femoral head involvement as determined in stage IV
              & estimated acetabular involvement)


 VI Advanced degenerative changes

From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head:
   Results of core decompression and grafting with electrical stimulation
 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
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
Mitchell’s MRI Staging
Class     T1             T2             Definition


A         Bright         Intermediate   Fat signal


B         Bright         Bright         Blood signal


C         Intermediate   Bright         Fluid or edema
                                        signal

D         Dark           Dark           Fibrosis signal
Criteria For Diagnosis
           (Current Concept JBJS Mont & Hungerford)

Specific Criteria                    Non specific criteria
 Collapse of femoral head           Collapse of femoral head with
                                     narrowing of joint space
 Subchondral radiolucent line
                                     Mottled ,cystic & sclerotic pattern in
 Anterolateral sequestrum           head
 Bone scan showing a photopenic     MRI showing changes in bone
  region surronded by area of
  increased density                  marrow

 Double band on T2-weighted         Painful movements of hip with
  image                              normal X ray

 Bone biopsy showing empty           H/O of alcohol & steroid intake
  lacunae involving multiple adjacent
  trabeculae                          Non specific but abnormal biopsy ,
                                      edema /fibrois
AIM OF TREATMENT


 Preserve rather than Replacing Femoral Head &
  Cartilage

 Early Intervention has favorable impact on the
 disease prognosis irrespective of T/t modality
 used
Medical Management
 Indications:-

 Small, Asymptomatic lesions

 Lesion is so advanced that prophylactic measures
  would be of little value

 When Sx is contraindicated or declined

 Buying time until arthroplasty is needed
PROTECTED WEIGHT BEARING
 Protect the involved area from excessive stress by using some form of limited
  weight bearing. Canes or even crutches are frequently prescribed

 Don’t alter the natural course of the disorder

 INDICATIONS:-

 Alternative to surgical management

 Small, Asymptomatic lesions
 low weight bearing area, such as the medial aspect of the femoral head

 Poor medical condition

 Following certain types of surgical procedures, such as core
  decompression, grafting, and osteotomies (used as an adjunct)


 Most important role :relatively advanced stages of osteonecrosis.
  Cane or Crutches can diminish symptoms and improve function considerably
  until such time as a reconstructive procedure is indicated
Glueck & colleagues => Incidence of
osteonecrosis in association with certain
Coagulopathies & Hyperlipidmias
Stanozolol anabolic androgenic steroid potenial
means of treating AVN associated with
Coagulopathies & Hyperlipidemias
Motomura et al => Incidence of Steroid-induced
osteonecrosis in rabbits using a combination of
Warfarin & Probucol (Lipid Lowering Agents)
ENAXOPARIN adminstered for 12 weeks was
found to prevent radiographic Progression of
Stage 1 and Stage 2 idiopathic osteonecrosis
of the femoral head at 2 year follow up
Gauthier => 95%-100% of transplant patients
who were treated with Calcium Channel
Blockers experienced complete relief of Bone
Pain Syndrome
I.V. ILIOPROST, a Vasoactive Prostacyclin
analogue showed significant improvements in
patients with Bone Marrow Edema Syndrome &
Osteonecrosis
Oral Nifedipine => Relief of bone pain reported
in a small series of patients with Osteonecrosis
Alendronate :- In a prospective study of 100 hips with
  osteonecrosis, Agarwal et al reported that l/t significant
  improvement in Pain & Disability scores

 Marrow edema improved on MRI & plain films were unchanged
  or progressed one grade

 In a prospective randomized study of 40 patients with stage II
  or III osteonecrosis & minimum 2-year follow-up, only 2 of 29
  patients taking alendronate experienced collapse of the femoral
   head, whereas 19 of 25 heads in the control group collapsed
Bisphosphonates => reportedly causing
Osteonecrosis of the Jaw , so should be used
cautiously
Puerarin :- An extract of the kudzu vine , is purported to
  Cholesterol, Platelet Aggregation & cause Vasodilation.

 In a study of Alcohol-induced Osteonecrosis in mice, puerarin
  was reported to lower serum cholesterol & to prevent the
  changes of osteonecrosis in femoral heads.

 No data on the use of puerarin for osteonecrosis in humans
  are available
Electric, Electromagnetic & Acoustic T/t

     Pulsed Electromagnetic Field stimulation, is
      reported to be useful for treatment of
      osteonecrosis in 4 reports.

     Mechanisms Of Action:-

 5.   Local control of inflammation

 7. Enhances repair activity & healing process by
    stimulating neovascularisation & new bone
    formation.
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)
Extracorporeal Shockwave Therapy
  There are only 2 papers in Pubmed

  The only study is by Wang et al who compared the
   results of such therapy in 23 patients (29 hips) with the
   results in a group treated with non-vascularized fibular
   grafting

  At a mean of 25 months, 79% of the shock-wave group
   had improved Harris Hip Scores compared with 29% of
   the group treated with non-vascularized fibular grafting
Hyperbaric oxygen (HBO)
 HBO improves oxygenation, reduces oedema & induces
  angioneogenesis, a reduction in intra osseous pressure
  & improvement in microcirculation

 Reis et al, 24 involving 16 hips in 12 patients, all with
  Steinberg Stage 1 disease, gave each patient 100
  consecutive days of HBO, which involved breathing
  100% oxygen via a maskat 2-2.4 atmospheres pressure
  for 90 minutes

 They reported that 13 of the 16 femoral heads
  subsequently appeared normal on MRI after this T/t
Bone Marrow Injections
 Supplemented with Core Decompression

  Principle:-

  The small no. of progenitor cells in the proximal extremity
  of the femur with osteonecrosis of the femoral head
  causes insufficient creeping substitution after
  osteonecrosis



  Red Bone Marrow Graft contains Osteogenic
  Precursors,which repopulate the osteonecrotic bone
Bone Marrow Injections
Technique

 Usual site => Anterior Iliac Crest

  A beveled metal trocar of 6 to 8 cm
  length & a bore of 1.5 mm is
  pushed deep into the cancellous
  bone

  Marrow is aspirated with A 10 ml
  syringe(flushed with heparin)

  Aspirates pooled in plastic bags
  containing an anticoagulant
  solution

  Filtered to remove fat aggregates &
  clots
                                        Trocar
Bone Marrow Injections
 Current Indications:-

 The best indications are hips with osteonecrosis &
  without collapse

 In some patients who had Steinberg stage III
  (subchondral crescent, no collapse), successful
  outcomes (no further surgery) have been obtained
  between 5 and 10 years. Therefore, in selected
  patients, even more advanced disease can be
  considered for core decompression
Bone Marrow Injections
Surgical procedures
Joint Preserving       Joint Replacing
 Core
                        Total Hip
 Decompression
                        Arthroplasty
 Various
                        Hip Resurfacing
 Nonvascularized &
                        Procedures
 Vascularized Bone
 Grafting Procedures

 Osteotomy
 Procedures
Core Decompression
 Core decompression was
  “discovered” by Paul Ficat
  & Jacques Arlet in the
  1960s

 Incidental discovery
Core Decompression
 Indications:-
 Core decompression is effective for symptomatic relief in
  nearly all stages in all patients who present with a painful
  hip secondary to ON d/t of intramedullary pressure done
  by it

 Transient symptomatic relief in an advanced stage & in
  already collapsing or when collapse is impending

 It is Most Effective in Stage I & II lesions that are size A
  (15% of head affected) & B (15%–30% of head affected)

  The larger the lesion, the less likely the patient is to have a
  successful outcome.
Core Decompression

Standard Technique & its Variations:-
 Ficat & Arlet proposed creating an 8 to 10 mm dia core
  track & this became a “standard”

 Recently some authors have suggested that the same effect
  of standard core can be achieved by producing Multiple
  Smaller Core Tracks of 3-mm dia range. This can be done
  percutaneously & theoretically # risk & shortens the
  operative time & morbidity

 Steinberg et al proposed making Smaller Angled Core
  Tracks into the Necrotic Segment from the Central Core
  Canal
Core Decompression
 Postoperative Management

 The lateral cortical window produces a stress riser in the
  proximal femur So Protect the patient from
  unprotected weightbearing for the first 6 weeks

 Reported incidence of # with core decompression is <1%
  & has almost always been associated with either a fall or
  failure to use protective devices (crutches or a walker) in
  the first 6 weeks
Bone Grafting Procedures

 Bone grafting procedures are a group of joint preserving
  techniques that involve the removal of the diseased femoral
  head segment, f/b its replacement with 1or more of a variety of
  bone graft options


 These are most valuable in treating patients with Stage I & II
  disease
Bone Grafting Procedures

 Techniques:-

 Grafting Through Lateral Core Track

 Grafting Through Femoral Neck Window

 Grafting Through Articular Surface Window
Grafting Through Lateral Core Track
Grafting Through Lateral Core Track
     Advantages:-

    Simple technique
    Minimal Invasiveness
    Avoidance of surgical dislocation of the hip
    Low Complication Rate
    Can be performed bilaterally under one anesthetic

     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 Femoral Neck Window
   Watson-Jones or Smith-Peterson approach
    is used

   A window is created to expose the anterior
    femoral neck, at the level of the junction of
    the femoral head & neck

   When Combined with a Bone Grafting
    procedure,refered as the “light bulb”
    procedure.

 Advantage is the improved access to the
    necrotic femoral head segment & the
    avoidance of direct iatrogenic cartilage
    damage

 Disadvantage is the creation of a cortical
    defect in the femoral neck, which raises the
    risk of fracture
Grafting Through Articular SurfaceWindow
 The 3rd method of accessing the necrotic segment of the femoral head is
  known as the “Trapdoor” approach

 With this method, the hip is surgically dislocated using a technique aimed at
  preserving the blood supply to the femoral head & neck

 Once exposed, a “trapdoor” window is made in the femoral head cartilage
  to access the diseased subchondral bone

 When combined with a bone grafting procedure, refered as the “Trapdoor”
  Procedure

 Advantage : Exposure allows a direct evaluation of the cartilage surface &
                  underlying diseased femoral head segment & allows for
                  precise bone graft placement.

 Disadvantage : Demanding technical nature
                     Iatrogenic cartilage damage & osteonecrosis
Grafting Through Articular SurfaceWindow
Types of Bone Grafts
 Nonvascularized Grafts          Vascularized Grafts
 Nonvascularized cortical     2. Local pedicled grafts,which
  bone grafts are typically        do not require microvascular
  prepared as several struts
  that provide structural          reanastomosis
  support under the articular  eg :Muscle-pedicle bone grafts
  surface within the evacuated     Vascularized pedicle bone
  segment                          grafts
 This construct is often
  augmented with cancellous 6. Free vascularized grafts,
  bone graft in an effort to       which require a
  improve its osteoconductive      microvascular
  and/or osteoinductive            reanastomosis.
  properties                  eg: Free vascularized fibula
                                   graft
Muscle-Pedicle Bone Grafts
Muscle-Pedicle Bone Grafts
 Baksi et al (1991) => results in treating 68 hips
  with a variety of muscle-pedicle bone grafts

 The preferred techniques were the tensor fascia
  lata-iliac crest graft anteriorly & the quadratus
  femoris posteriorly.
 Of note, 82% of the hips treated in the series
  demonstrated some degree of collapse

 At a mean follow-up of 7 years, there were good
  to excellent results in 83% of cases
Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
The harvested fibula with marbleized muscle attached confirming an
extraperiosteal dissection. The peroneal artery & two accompanying
veins
Proximal Femoral Osteotomies

 The main rationale proposed for the efficacy of
  osteotomies is the biomechanical effect of
  moving the collapsed/necrotic segment of the
  femoral head from the principal weight-bearing
  area of the hip to an area that bears less/no
  direct weight and to allow weight-bearing contact
  to now happen in an area of relatively normal
  bone and cartilage
Proximal Femoral Osteotomies
 Categories:-

 Valgus or varus osteotomies usually
  combined with flexion or extension

 Transtrochanteric rotational osteotomies
Proximal Femoral Osteotomies

 Indications:-

 For varus or valgus osteotomies depend
  on the location & size of the lesion

 Osteotomies may be used for both
  precollapse & postcollapse without
  notable acetabular involvement
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 AND
         BONE GRAFTING
VARUS OSTEOTOMY WITH FLEXION OR
          EXTENSION
ROTATIONAL OSTEOTOMIES
• Sugioka first reported a transtrochanteric
  transposition osteotomy with anterior
  rotation of the head and neck of
  the femur
ROTATIONAL OSTEOTOMY

             before rotation
                                                  After rotation




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
ROTATIONAL OSTEOTOMY
Hip Resurfacing Procedures

Femoral & Acetabular Surface Replacement & Hemi-
 Surface Replacement for Osteonecrosis of the Hip

  Indications :-

 Later stages of osteonecrosis (University of Pennsylvania
  Stage III–VI)

 > 30% femoral head involvement
Metal-on Polyethylene Resurfacing
    Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971)
    independently were the first to perform metal-on polyethylene
    resurfacing

 Townley introduced a total articular resurfacing arthroplasty
  (TARA; Depuy, Warsaw,IN) that resurfaced the femoral head
  with a metal component while replacing the articulating surface
  of the acetabulum with a thin, plastic shell inserted with cement

 Metal-on-polyethylene resurfacing yielded
  unacceptably high failure rates. The
  polyethylene-induced osteolysis resulting
  from the mating of large metal femoral
  head components with thin diameter
  acetabular cups
Metal-on-Metal Bearings


 Reduces the
  incidence of long-term
  failure from aseptic
  loosening &
  osteolysis
Total Hip Replacement

 TOC for advanced osteonecrosis of the hip (University of
  Pennsylvania Stages IVB–VIC)


 Excellent pain relief & functional improvements


 More recent studies at intermediate follow up up to 10
  years have demonstrated similar survivorship compared
  to total hip replacement for osteoarthrosis.
Bhumika – Non Cemented THR
Miscllaneous Procedures

 FEMORAL ENDOPROSTHESIS

 ARTHRODESIS

 RESECTION ARTHROPLASTY

 ACRYLIC CEMENT INJECTION
Femoral Endoprosthesis
 Initial changes are in the
  femoral head and not the
  acetabulum



 Replacing the femoral
  head would also be more
  conservative than the
  additive procedure of
  acetabular reconstruction,
  allowing for later simple
  conversion to total hip
  arthroplasty
Arthrodesis
 Mostly a salvage procedure in contemporary orthopedics

 In the patient with significant pain & disability & in whom
  nonsurgical T/t has failed with a contraindication to
  prosthetic replacement

 Clinical success can be achieved as it may relieve hip pain

 The recommended position is 0° to 5° of adduction, 25° to
  30° of flexion & 0° to 15° of external rotation

 Later revision to a THR has a significant complication
  rate with less functional outcome
Resection Arthroplasty
 T/t of last resort

 Complete resection of the head & neck of the femur

 Can achieve a good range of pain-free motion & will be able to
  function reasonably well for most activities of daily living

 The use of a shoe lift is generally necessary as a result of the
  shortening of the extremity, which averages approximately 1.5
  inches

 There will be a noticeable abductor lurch & patients will
  require some form of assistive device for ambulation

 Indication:- patient with severe pain and disability who is not a
Acrylic Cement Injection
 Debriding the necrotic zone then elevating & supporting the
  collapsed segment by the injection of cement

 Wood and coworkers reported on very preliminary results 21
  of 20 cases

 All patients realized immediate pain relief with improved hip
  scores, with 3 patients undergoing early conversion to total hip
  arthroplasty

 Relatively invasive but may have the advantage of maintaining
  femoral head congruity

 Long-term results with perhaps a randomized controlled series
  will be necessary if this is a viable alternative to reconstructive
  surgery
POROUS TANTALUM ROD INSERTION




 A novel approach in T/t of stage I & II precollapse osteonecrosis

 This rod functions analogously to a Cortical Strut Graft allowing
  structural & osteoconductive properties
POROUS TANTALUM ROD INSERTION
Sir Astley Paston COOPER
                            1768–1841



“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
knowledge. Observations on diseased living, examinations of the dead &
     experiments upon living animals are the only sources of true
                             knowledge.”
Thank you

Contenu connexe

Tendances

Periprosthetic fracture
Periprosthetic fracturePeriprosthetic fracture
Periprosthetic fracturejatinder12345
 
Surgical Approaches to Acetabulum and Pelvis
Surgical Approaches to Acetabulum and PelvisSurgical Approaches to Acetabulum and Pelvis
Surgical Approaches to Acetabulum and PelvisBijay Mehta
 
Salter's innominate osteotomy
Salter's innominate osteotomySalter's innominate osteotomy
Salter's innominate osteotomyHardik Pawar
 
Lateral condyle fracture of humerus in children
Lateral condyle fracture of humerus in childrenLateral condyle fracture of humerus in children
Lateral condyle fracture of humerus in childrenAiman Ali
 
CORA (center of rotation of angulation)
CORA (center of rotation of angulation)CORA (center of rotation of angulation)
CORA (center of rotation of angulation)Morshed Abir
 
Proximal Tibia Surgical approaches
Proximal Tibia Surgical approachesProximal Tibia Surgical approaches
Proximal Tibia Surgical approachesMOHAMMED ROSHEN
 
Principles of deformity correction
Principles of deformity correctionPrinciples of deformity correction
Principles of deformity correctionAbdulla Kamal
 
Absolute stability plate fixation
Absolute stability plate fixationAbsolute stability plate fixation
Absolute stability plate fixationSitanshu Barik
 
DISTAL END RADIUS FRACTURE
DISTAL END RADIUS FRACTURE DISTAL END RADIUS FRACTURE
DISTAL END RADIUS FRACTURE vashisth narayan
 
Telescopic nails in Osteogenesis Imperfecta
Telescopic nails in Osteogenesis ImperfectaTelescopic nails in Osteogenesis Imperfecta
Telescopic nails in Osteogenesis ImperfectaShady Mahmoud
 
Damage Control Orthopaedics (DCO)
 Damage Control Orthopaedics (DCO) Damage Control Orthopaedics (DCO)
Damage Control Orthopaedics (DCO)fathi neana
 
Clinical Examination of the Hip
Clinical Examination of the HipClinical Examination of the Hip
Clinical Examination of the Hiporthoprince
 
Perilunate dislocations
Perilunate dislocationsPerilunate dislocations
Perilunate dislocationsRashik Ismail
 
Poller or blocking screw
Poller or blocking screwPoller or blocking screw
Poller or blocking screwAvik Sarkar
 
Damage control orthopaedic surgery
Damage control orthopaedic surgeryDamage control orthopaedic surgery
Damage control orthopaedic surgeryMohamed Abulsoud
 
Calcaneal fractures
Calcaneal fracturesCalcaneal fractures
Calcaneal fracturesRohit Vikas
 

Tendances (20)

Periprosthetic fracture
Periprosthetic fracturePeriprosthetic fracture
Periprosthetic fracture
 
Surgical Approaches to Acetabulum and Pelvis
Surgical Approaches to Acetabulum and PelvisSurgical Approaches to Acetabulum and Pelvis
Surgical Approaches to Acetabulum and Pelvis
 
Lecture 42 shah calcaneal malunions
Lecture 42 shah calcaneal malunionsLecture 42 shah calcaneal malunions
Lecture 42 shah calcaneal malunions
 
Acetabular defects
Acetabular defectsAcetabular defects
Acetabular defects
 
Salter's innominate osteotomy
Salter's innominate osteotomySalter's innominate osteotomy
Salter's innominate osteotomy
 
Pcl avulsion
Pcl avulsionPcl avulsion
Pcl avulsion
 
Lateral condyle fracture of humerus in children
Lateral condyle fracture of humerus in childrenLateral condyle fracture of humerus in children
Lateral condyle fracture of humerus in children
 
CORA (center of rotation of angulation)
CORA (center of rotation of angulation)CORA (center of rotation of angulation)
CORA (center of rotation of angulation)
 
Proximal Tibia Surgical approaches
Proximal Tibia Surgical approachesProximal Tibia Surgical approaches
Proximal Tibia Surgical approaches
 
Principles of deformity correction
Principles of deformity correctionPrinciples of deformity correction
Principles of deformity correction
 
Absolute stability plate fixation
Absolute stability plate fixationAbsolute stability plate fixation
Absolute stability plate fixation
 
DISTAL END RADIUS FRACTURE
DISTAL END RADIUS FRACTURE DISTAL END RADIUS FRACTURE
DISTAL END RADIUS FRACTURE
 
Telescopic nails in Osteogenesis Imperfecta
Telescopic nails in Osteogenesis ImperfectaTelescopic nails in Osteogenesis Imperfecta
Telescopic nails in Osteogenesis Imperfecta
 
Damage Control Orthopaedics (DCO)
 Damage Control Orthopaedics (DCO) Damage Control Orthopaedics (DCO)
Damage Control Orthopaedics (DCO)
 
Clinical Examination of the Hip
Clinical Examination of the HipClinical Examination of the Hip
Clinical Examination of the Hip
 
Perilunate dislocations
Perilunate dislocationsPerilunate dislocations
Perilunate dislocations
 
Poller or blocking screw
Poller or blocking screwPoller or blocking screw
Poller or blocking screw
 
Damage control orthopaedic surgery
Damage control orthopaedic surgeryDamage control orthopaedic surgery
Damage control orthopaedic surgery
 
Approaches of forearm
Approaches of forearmApproaches of forearm
Approaches of forearm
 
Calcaneal fractures
Calcaneal fracturesCalcaneal fractures
Calcaneal fractures
 

En vedette

Radial club hand
Radial club handRadial club hand
Radial club handdralizameer
 
High tibial osteotomy
High tibial osteotomyHigh tibial osteotomy
High tibial osteotomyorthoprince
 
Arthroscopic cuff repair
Arthroscopic cuff repairArthroscopic cuff repair
Arthroscopic cuff repairorthoprince
 
2009 oite review
2009 oite review2009 oite review
2009 oite reviewssweet3237
 
Clinical examination of hip:Long Case
Clinical examination of hip:Long CaseClinical examination of hip:Long Case
Clinical examination of hip:Long CaseSuman Kumar
 
SLAP Tears repair vs tenodesis
SLAP Tears repair vs tenodesisSLAP Tears repair vs tenodesis
SLAP Tears repair vs tenodesisorthoprince
 
Osteotomies around hip by dr rohit kumar
Osteotomies around hip by dr rohit kumarOsteotomies around hip by dr rohit kumar
Osteotomies around hip by dr rohit kumarDr Rohit Kumar
 
Tuberculosis Spine
Tuberculosis SpineTuberculosis Spine
Tuberculosis Spineorthoprince
 
Evidence-based Medicine
Evidence-based MedicineEvidence-based Medicine
Evidence-based Medicineshabeel pn
 
Examination of the hip
Examination of the hipExamination of the hip
Examination of the hiporthoprince
 
Meniscus Transplant
Meniscus TransplantMeniscus Transplant
Meniscus Transplantsfkneerobot
 
Management of Hip Dislocations
Management of Hip DislocationsManagement of Hip Dislocations
Management of Hip Dislocationsahmedashourful
 
Reflex sympathetic dystrophy (1)
Reflex sympathetic dystrophy  (1)Reflex sympathetic dystrophy  (1)
Reflex sympathetic dystrophy (1)orthoprince
 
Initial Assessment And Management
Initial Assessment And ManagementInitial Assessment And Management
Initial Assessment And Managementkk 555888
 
BroströM Procedure Presentation
BroströM Procedure PresentationBroströM Procedure Presentation
BroströM Procedure PresentationLEDocDave
 

En vedette (20)

Radial club hand
Radial club handRadial club hand
Radial club hand
 
High tibial osteotomy
High tibial osteotomyHigh tibial osteotomy
High tibial osteotomy
 
Arthroscopic cuff repair
Arthroscopic cuff repairArthroscopic cuff repair
Arthroscopic cuff repair
 
Bone grafting
Bone graftingBone grafting
Bone grafting
 
2009 oite review
2009 oite review2009 oite review
2009 oite review
 
Clinical examination of hip:Long Case
Clinical examination of hip:Long CaseClinical examination of hip:Long Case
Clinical examination of hip:Long Case
 
SLAP Tears repair vs tenodesis
SLAP Tears repair vs tenodesisSLAP Tears repair vs tenodesis
SLAP Tears repair vs tenodesis
 
Osteotomies around hip by dr rohit kumar
Osteotomies around hip by dr rohit kumarOsteotomies around hip by dr rohit kumar
Osteotomies around hip by dr rohit kumar
 
Tuberculosis Spine
Tuberculosis SpineTuberculosis Spine
Tuberculosis Spine
 
Posterior gleno-humeral-instability
Posterior gleno-humeral-instabilityPosterior gleno-humeral-instability
Posterior gleno-humeral-instability
 
Evidence-based Medicine
Evidence-based MedicineEvidence-based Medicine
Evidence-based Medicine
 
Examination of the hip
Examination of the hipExamination of the hip
Examination of the hip
 
Tennis elbow
Tennis elbowTennis elbow
Tennis elbow
 
Shoulder
ShoulderShoulder
Shoulder
 
Bone Tumors
Bone TumorsBone Tumors
Bone Tumors
 
Meniscus Transplant
Meniscus TransplantMeniscus Transplant
Meniscus Transplant
 
Management of Hip Dislocations
Management of Hip DislocationsManagement of Hip Dislocations
Management of Hip Dislocations
 
Reflex sympathetic dystrophy (1)
Reflex sympathetic dystrophy  (1)Reflex sympathetic dystrophy  (1)
Reflex sympathetic dystrophy (1)
 
Initial Assessment And Management
Initial Assessment And ManagementInitial Assessment And Management
Initial Assessment And Management
 
BroströM Procedure Presentation
BroströM Procedure PresentationBroströM Procedure Presentation
BroströM Procedure Presentation
 

Similaire à Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)

avascularnecrosisfemoralhead12-120721082011-phpapp02.pptx
avascularnecrosisfemoralhead12-120721082011-phpapp02.pptxavascularnecrosisfemoralhead12-120721082011-phpapp02.pptx
avascularnecrosisfemoralhead12-120721082011-phpapp02.pptxadhithyan16
 
Avascular necrosis
Avascular necrosisAvascular necrosis
Avascular necrosisshyamsobti
 
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. Panditrao
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoDeep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. Panditrao
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
 
Avascular necross
Avascular necrossAvascular necross
Avascular necrossramarawand
 
Perthes disease in children
Perthes disease in childrenPerthes disease in children
Perthes disease in childrendocortho Patel
 
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...Farooq Yadwad
 
avn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdfavn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdfMohammedTauheed5
 
Avascular necrosis of the hip
Avascular necrosis of the hipAvascular necrosis of the hip
Avascular necrosis of the hipdedde1
 
CES 2016 02 - Oncologic emergencies
CES 2016 02 - Oncologic emergenciesCES 2016 02 - Oncologic emergencies
CES 2016 02 - Oncologic emergenciesMauricio Lema
 
Avascular necrosis of femur
Avascular necrosis of femurAvascular necrosis of femur
Avascular necrosis of femurPratikDhabalia
 
Avascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral HeadAvascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral HeadQazi Manaan
 
marfansyndrome-220129064039.pptx
marfansyndrome-220129064039.pptxmarfansyndrome-220129064039.pptx
marfansyndrome-220129064039.pptxasdgja
 
Agnesian HealthCare Know & Go Friday, February 2017: Vascular Surgery
Agnesian HealthCare Know & Go Friday, February 2017: Vascular SurgeryAgnesian HealthCare Know & Go Friday, February 2017: Vascular Surgery
Agnesian HealthCare Know & Go Friday, February 2017: Vascular SurgeryAgnesian HealthCare
 

Similaire à Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics) (20)

avascularnecrosisfemoralhead12-120721082011-phpapp02.pptx
avascularnecrosisfemoralhead12-120721082011-phpapp02.pptxavascularnecrosisfemoralhead12-120721082011-phpapp02.pptx
avascularnecrosisfemoralhead12-120721082011-phpapp02.pptx
 
AVN
AVNAVN
AVN
 
Avn
AvnAvn
Avn
 
Avascular necrosis
Avascular necrosisAvascular necrosis
Avascular necrosis
 
Avascular necrosis
Avascular necrosisAvascular necrosis
Avascular necrosis
 
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. Panditrao
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoDeep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. Panditrao
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. Panditrao
 
Marfan Syndrome pdf
Marfan Syndrome pdfMarfan Syndrome pdf
Marfan Syndrome pdf
 
Avascular necross
Avascular necrossAvascular necross
Avascular necross
 
Perthes disease in children
Perthes disease in childrenPerthes disease in children
Perthes disease in children
 
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...
Anesthetic implications of TOTAL HIP REPLACEMENT and TOTAL KNEE Replacement s...
 
avn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdfavn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdf
 
Avascular necrosis of the hip
Avascular necrosis of the hipAvascular necrosis of the hip
Avascular necrosis of the hip
 
Avascular necross
Avascular necrossAvascular necross
Avascular necross
 
Bindhya dvt
Bindhya dvtBindhya dvt
Bindhya dvt
 
CES 2016 02 - Oncologic emergencies
CES 2016 02 - Oncologic emergenciesCES 2016 02 - Oncologic emergencies
CES 2016 02 - Oncologic emergencies
 
Avascular necrosis of femur
Avascular necrosis of femurAvascular necrosis of femur
Avascular necrosis of femur
 
Avascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral HeadAvascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral Head
 
marfansyndrome-220129064039.pptx
marfansyndrome-220129064039.pptxmarfansyndrome-220129064039.pptx
marfansyndrome-220129064039.pptx
 
Agnesian HealthCare Know & Go Friday, February 2017: Vascular Surgery
Agnesian HealthCare Know & Go Friday, February 2017: Vascular SurgeryAgnesian HealthCare Know & Go Friday, February 2017: Vascular Surgery
Agnesian HealthCare Know & Go Friday, February 2017: Vascular Surgery
 
Marfan syndrome
Marfan syndromeMarfan syndrome
Marfan syndrome
 

Dernier

SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 

Dernier (20)

SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 

Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)

  • 1. AVASCULAR NECROSIS FEMORAL HEAD By : Dr. Rajat Malot Assistant Professor SMS Medical college Jaipur
  • 2. 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
  • 3. Anterior Hip pain or Lateral pain or Posterior hip pain Groin pain Trochanteric pain Rule out: hip Rule out: hip Rule out: sciatic fracture, septic joint, fracture, bone tumor, nerve irritation and avascular referred pain from ,sacroiliitis due to necrosis lumbar disc spondyloarthropathy, herniation lumbardisc or facet disease Other causes:OA, Other causes: RA, trochanteric iliopectineal bursitis bursitis,OA, radiating Other causes:muscle from strain lumbar disc or facet disease
  • 4. CLINICAL PRESENTATION  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
  • 5. Characteristics Of Pain  Focal over the groin / hip or it may radiate to the buttocks, anteromedial thigh or knee  Induced mechanically by standing & walking & may be eased by rest  May be very intense, throbbing, deep & often intermittent  Worsened by coughing & at night  40% of patients have night pain asso. with morning stiffness  A Click may be heard when the patient rises from a sitting position or on external rotation of an abducted hip
  • 6. Range Of Motion  ROM may be diminished, especially after collapse of the femoral head  ROM may be limited, especially in flexion, abduction & internal rotation  Gait :- Patients may walk with a limp.  The Trendelenburg sign may be Positive  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
  • 7. BLOOD SUPPLY OF FEMORAL HEAD  The principal sources are the Lateral Epiphyseal Vessels (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) supplies medial third of the femoral head.  Branches of LEVs & ALT anastomose at the junction of central & medial 1/3 of the femoral head
  • 8. lateral circumflex A. Medial circumflex A. BLOOD SUPPLY OF FEMORAL HEAD
  • 9. Blood Supply in Paediatric Age Gp.  Till 4-7 years of age, the vascular anatomy in a age 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.
  • 10. AVN HISTORY  Konig (1888) => first described the condition coined the term Osteochondritis Dissecans  Haenish (1925) => first case of idiopathic ischemic necrosis of the femoral head in an adult  Arterial Occlusion (1940) was postulated as the cause of the necrosis.  Pietrograndi (1957) => AVN d/t Steroid therapy
  • 11. AVASCULAR NECROSIS  Misnomer; Basically it is Osteonecrosis (dead bone)  Also c/a Osteochondritis Dissecans / Chandler’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 $)
  • 12. AVASCULAR NECROSIS  M/c affects => Femoral Head  M/c site => Anterolateral aspect (Being principal Wt. bearing portion)  Incidence d/t Steroid usage & Trauma  AVN only occurs in FATTY MARROW, which contains MARROW a Sparse vascular supply. In contrast to Hematopoietic supply marrow which has a rich blood supply
  • 13. Does Elderly Persons are at increased risk for AVN????? AVN 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 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.
  • 14. ETIOLOGY Intravascular Extravascular Extraosseous  Intraosseous vascular factor factors I. Arterial factors  Capsular factors Intraosseous vascular factors I. Arterial factors II. Venous factors
  • 15. Extraosseous Vascular Factors Arterial Factors  Most important  Femoral Head blood supply is an End-Organ System with poor collateral development  Trauma to the hip may l/t contusion or mechanical interruption to the Lateral Retinacular Vessels (main blood supply of the femoral head & neck)
  • 16. Intraosseous Vascular Factors Arterial Factors  Circulating microemboli that block the microcirculation of the femoral head  In Conditions like- 6. Fat emboli (hyperlipidemia associated with alcoholism) 7. steroid therapy 8. SCD 9. nitrogen bubbles in decompression sickness
  • 17. Intraosseous Vascular Factors Venous Factors  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 drainage Reducing venous outflow & causing stasis  S/i Caisson disease & SCD
  • 18. Extravascular Factors Intraosseous Factors  Ficat et al demonstrated increased bone marrow pressure in the femoral necks of a large number of patients with avascular necrosis of the femoral head (AVN). Steroid Alcohol & Steroid Hypertrophy of Fat cells Gaucher cells & Inflammatory cells Encroach on intraosseous capillaries Direct toxic metabolic Intramedullary circulation effect on osteogenic cells Compartment syndrome
  • 19. Extravascular Factors Capsular Factors Trauma, Infection & Arthritis Effusions within the Hip joint Intracapsular Pressure Tamponade of the LEVs
  • 20. SEQUELAE OF AVN Minimal AVN More Severe AVN  Avascular area is small  Once AVN develops, repair & is not adjacent to an Begins at the interface b/w articular surface. viable bone & necrotic bone  Patient may be Asymptomatic  Ineffective Resorption of  Healing may occur dead bone within the necrotic spontaneously or the focus is the rule. disease may remain Mixed sclerotic and cystic undetected appearance on radiographs.
  • 21. SEQUELAE OF AVN MECHANICAL FAILURE Non-healing Micro# in Subchondral region Collapse of the Vicious Cycle Diffuse Subchondral # Articular Cartilage X-Ray :- Crescent Progressive Wt. Bearing Degenerative joint disease (DJD) & Joint Dissolution
  • 22. CAUSES  Trauma  Gout and hyperuricemia  Alcohol consumption  Hypercholesterolemia  Corticosteroid intake  Hypercoagulable states  Hypercortisolism  Hyperlipidemia  Cushing disease  Hyperparathyroidism  Hemoglobinopathies  Intravascular coagulation (SCD;Hb S/C;Polycythemia)  Organ transplantation  Caisson disease  Pregnancy (Dysbaric osteonecrosis)  Congenital dislocation Hip  Pancreatitis  Ehlers-Danlos synd  Neoplasms  Heredity dysostosis  CRF  Legg-Calvé-Perthes dis  Hemodialysis  Fabry disease  Cigarette smoking  Gaucher disease  Collagen Vascular dis.  Giant cell arteritis  SLE  Thrombophlebitis  Idiopathic
  • 23. Mechanism of Development of AVN d/t Trauma
  • 24. CAUSES Steroid (35-40%)  6 mechanisms • Fat Emboli from the liver => Occlusion of Small Vessels • Steroid Intramedullary Fat Cells Size without an equivalent compensatory loss of trabecular & cortical bone => Intraosseous pressure • Fat Emboli Hydrolysis FFAs Toxic to vascular endo. Intravascular Coagulation • Synthesis of Polyclonal Antithyroid Hormone Receptor Alpha-Ab (-) Angiogenesis Proteolytic Activity 10.A direct toxic effect occursSteroid Induced Blood Flow on osteogenic cells 11.Hematopoietic Marrow Fatty Marrow  > 20 mg & 6 Wks => Risk
  • 25. Investigations MRI SPECT CT Scan Plain X-Ray  Most Sensitive  Reflects Vascular Integrity  Unable to detect disease of  1.5-T magnet  Avascular Focus may be stage 0 or 1 88% sensitivity demonstrated Early in 100% specificity Disease (MRI Contrast)  Helpful in assessing flattening of the Femoral Head & asso. 94% accuracy  85% sensitivity Degen. changes (Beltran et al) (Collier)  For Extent of Involvement  Indispensable for  Triple-Head High- e.g. Subchondral Lucencies Accurate Staging resolution SPECT & Sclerosis during Reparative stage of AVN because Sensitivity 97% images clearly depict (Lee et al)  Enables detection of subchondral or 12. Size of the lesion cancellous # & collapse 13. Gross estimates of
  • 26. Radiology- sequential Changes • Crescent Sign • Osteoporosis • Sclerosis • Cystic changes • Loss of spherical weight bearing dome • Partial collapse of head • Secondary Osteoarthritis
  • 29. MRI Findings  Classic Findings:- look for focal lesion in the anterosuperior portion of femoral head that is well demarcated but is inhomogeneous  T1 images => low signal intensity  T2 images => double line sign => classic sign of AVN, made up of 2 concentric low and high signal bands  high-signal-intensity line may represent hypervascular granulation tissue
  • 30. MRI T1 image ∀ ↓ signal from ischemic marrow • Single band like area of low signal intensity. • 100% sensitivity • 98% specificity
  • 31. Double Line sign – T2 image • A second high signal intensity seen within the line seen on T1 images. • Represent hyper vascular granulation tissue
  • 32. Early
  • 35. Prominent & Thickened but Normal Trabeculae ASTERISK SIGN Axial CT: Patient without AVN of the Femoral Head
  • 39. TRANSIENT OSTEOPOROSIS OF THE HIP (TOH) D/D:-  No findings of bone infarction or repair, which are the hallmarks of osteonecrosis  The pathologic picture is primarily one of marrow edema, hence also referred to as Bone marrow edema syndrome (BMES)  Clinically, pain is usually more sudden, severe  in females esp.during 3rd trimester of pregnancy  Dx can be made readily based on MRI in most cases  TOH is usually self-limited.T/t is protected weight bearing to prevent #. Infrequently, core decompression may be indicated if a patient has an 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 in the T2-weighted image
  • 41. CLASSIFICATION & STAGING • In the 1960s, Arlet & Ficat in France described a 3-part staging system & in the 1970s a 4th stage was added Paul FICAT This form is perhaps the one most widely used now, despite the fact that a stage 0 & a transitional stage were added later
  • 42. Paul FICAT 1917-1986  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
  • 43. Ficat & Arlet Classification t Stages of Bone Necrosis 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
  • 44. A major disadvantage was that it didn’t include any measurement of lesion size or articular surface involvement..
  • 45. Radiographic Staging (Marcus et al 1973)  Stage 1 : Asymptomatic, mottled increased density of femoral head  Stage 2 : Asymptomatic , area of necrosis demarcated by a rim of increased density  Stage 3 : Intermittent pains, Crescent sign in frog lateral view  Stage 4 : Painful limb & flattening of femoral head  Stage 5 : Symptoms & signs of degenerative arthritis  Stage 6 : Severe degenerative arthritis
  • 46. Steinberg et al (1995) Modified Ficat & Arlet Classification Stage 0 – 3 :- Same as Ficat Arlet Stage 4 :- Flattening of femoral head Stage 5 :- Joint narrowing with or without acetabular involvement Stage 6 :- Advanced degenerative changes These stages were further divided into Mild, Moderate & Severe
  • 47.  1974, Kerboul et al noted that the results of osteotomies performed for osteonecrosis depended on both the location & the 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 , Sugioka et al. and Koo and Kim
  • 48. Kerboul:- combined necrotic angle – AP LAT
  • 49. University Of Pennsylvania Classification of Osteonecrosis  0 Normal or nondiagnostic x-ray, bone scan, and MRI  I Normal x-ray; abnormal bone scan and/or MRI A. Mild (15% of femoral head affected) B. Moderate (15%–30%) C. Severe (30%)  II “Cystic” and sclerotic changes in femoral head A. Mild (15% of femoral head affected) B. Moderate (15%–30%) C. Severe (30%)  III Subchondral collapse (‘Crescent Sign’) without flattening A. Mild (15% of articular surface) B. Moderate (15%–30%) C. Severe (30%)
  • 50. University Of Pennsylvania Classification of Osteonecrosis  IV Flattening of femoral head A. Mild (15% of surface and 2 mm depression) B. Moderate (15%–30% of surface or 2–4 mm depression) C. Severe (30% of surface or 4 mm depression)  V Joint narrowing and/or acetabular changes A. Mild (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement) B. Moderate (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement) C. Severe (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)  VI Advanced degenerative changes From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head: Results of core decompression and grafting with electrical stimulation
  • 51.  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
  • 53. Mitchell’s MRI Staging Class T1 T2 Definition A Bright Intermediate Fat signal B Bright Bright Blood signal C Intermediate Bright Fluid or edema signal D Dark Dark Fibrosis signal
  • 54. Criteria For Diagnosis (Current Concept JBJS Mont & Hungerford) Specific Criteria Non specific criteria  Collapse of femoral head Collapse of femoral head with narrowing of joint space  Subchondral radiolucent line Mottled ,cystic & sclerotic pattern in  Anterolateral sequestrum head  Bone scan showing a photopenic MRI showing changes in bone region surronded by area of increased density marrow  Double band on T2-weighted Painful movements of hip with image normal X ray  Bone biopsy showing empty H/O of alcohol & steroid intake lacunae involving multiple adjacent trabeculae Non specific but abnormal biopsy , edema /fibrois
  • 55. AIM OF TREATMENT  Preserve rather than Replacing Femoral Head & Cartilage  Early Intervention has favorable impact on the disease prognosis irrespective of T/t modality used
  • 56. Medical Management Indications:-  Small, Asymptomatic lesions  Lesion is so advanced that prophylactic measures would be of little value  When Sx is contraindicated or declined  Buying time until arthroplasty is needed
  • 57. PROTECTED WEIGHT BEARING  Protect the involved area from excessive stress by using some form of limited weight bearing. Canes or even crutches are frequently prescribed  Don’t alter the natural course of the disorder INDICATIONS:-  Alternative to surgical management  Small, Asymptomatic lesions  low weight bearing area, such as the medial aspect of the femoral head  Poor medical condition  Following certain types of surgical procedures, such as core decompression, grafting, and osteotomies (used as an adjunct)  Most important role :relatively advanced stages of osteonecrosis. Cane or Crutches can diminish symptoms and improve function considerably until such time as a reconstructive procedure is indicated
  • 58. Glueck & colleagues => Incidence of osteonecrosis in association with certain Coagulopathies & Hyperlipidmias
  • 59. Stanozolol anabolic androgenic steroid potenial means of treating AVN associated with Coagulopathies & Hyperlipidemias
  • 60. Motomura et al => Incidence of Steroid-induced osteonecrosis in rabbits using a combination of Warfarin & Probucol (Lipid Lowering Agents)
  • 61. ENAXOPARIN adminstered for 12 weeks was found to prevent radiographic Progression of Stage 1 and Stage 2 idiopathic osteonecrosis of the femoral head at 2 year follow up
  • 62. Gauthier => 95%-100% of transplant patients who were treated with Calcium Channel Blockers experienced complete relief of Bone Pain Syndrome
  • 63. I.V. ILIOPROST, a Vasoactive Prostacyclin analogue showed significant improvements in patients with Bone Marrow Edema Syndrome & Osteonecrosis
  • 64. Oral Nifedipine => Relief of bone pain reported in a small series of patients with Osteonecrosis
  • 65. Alendronate :- In a prospective study of 100 hips with osteonecrosis, Agarwal et al reported that l/t significant improvement in Pain & Disability scores  Marrow edema improved on MRI & plain films were unchanged or progressed one grade  In a prospective randomized study of 40 patients with stage II or III osteonecrosis & minimum 2-year follow-up, only 2 of 29 patients taking alendronate experienced collapse of the femoral head, whereas 19 of 25 heads in the control group collapsed
  • 66. Bisphosphonates => reportedly causing Osteonecrosis of the Jaw , so should be used cautiously
  • 67. Puerarin :- An extract of the kudzu vine , is purported to Cholesterol, Platelet Aggregation & cause Vasodilation.  In a study of Alcohol-induced Osteonecrosis in mice, puerarin was reported to lower serum cholesterol & to prevent the changes of osteonecrosis in femoral heads.  No data on the use of puerarin for osteonecrosis in humans are available
  • 68. Electric, Electromagnetic & Acoustic T/t  Pulsed Electromagnetic Field stimulation, is reported to be useful for treatment of osteonecrosis in 4 reports.  Mechanisms Of Action:- 5. Local control of inflammation 7. Enhances repair activity & healing process by stimulating neovascularisation & new bone formation.
  • 69. 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)
  • 70. Extracorporeal Shockwave Therapy  There are only 2 papers in Pubmed  The only study is by Wang et al who compared the results of such therapy in 23 patients (29 hips) with the results in a group treated with non-vascularized fibular grafting  At a mean of 25 months, 79% of the shock-wave group had improved Harris Hip Scores compared with 29% of the group treated with non-vascularized fibular grafting
  • 71. Hyperbaric oxygen (HBO)  HBO improves oxygenation, reduces oedema & induces angioneogenesis, a reduction in intra osseous pressure & improvement in microcirculation  Reis et al, 24 involving 16 hips in 12 patients, all with Steinberg Stage 1 disease, gave each patient 100 consecutive days of HBO, which involved breathing 100% oxygen via a maskat 2-2.4 atmospheres pressure for 90 minutes  They reported that 13 of the 16 femoral heads subsequently appeared normal on MRI after this T/t
  • 72. Bone Marrow Injections  Supplemented with Core Decompression Principle:- The small no. of progenitor cells in the proximal extremity of the femur with osteonecrosis of the femoral head causes insufficient creeping substitution after osteonecrosis Red Bone Marrow Graft contains Osteogenic Precursors,which repopulate the osteonecrotic bone
  • 73. Bone Marrow Injections Technique  Usual site => Anterior Iliac Crest A beveled metal trocar of 6 to 8 cm length & a bore of 1.5 mm is pushed deep into the cancellous bone Marrow is aspirated with A 10 ml syringe(flushed with heparin) Aspirates pooled in plastic bags containing an anticoagulant solution Filtered to remove fat aggregates & clots Trocar
  • 74. Bone Marrow Injections Current Indications:-  The best indications are hips with osteonecrosis & without collapse  In some patients who had Steinberg stage III (subchondral crescent, no collapse), successful outcomes (no further surgery) have been obtained between 5 and 10 years. Therefore, in selected patients, even more advanced disease can be considered for core decompression
  • 76. Surgical procedures Joint Preserving Joint Replacing  Core  Total Hip Decompression Arthroplasty  Various  Hip Resurfacing Nonvascularized & Procedures Vascularized Bone Grafting Procedures  Osteotomy Procedures
  • 77. Core Decompression  Core decompression was “discovered” by Paul Ficat & Jacques Arlet in the 1960s  Incidental discovery
  • 78. Core Decompression Indications:-  Core decompression is effective for symptomatic relief in nearly all stages in all patients who present with a painful hip secondary to ON d/t of intramedullary pressure done by it  Transient symptomatic relief in an advanced stage & in already collapsing or when collapse is impending  It is Most Effective in Stage I & II lesions that are size A (15% of head affected) & B (15%–30% of head affected) The larger the lesion, the less likely the patient is to have a successful outcome.
  • 79. Core Decompression Standard Technique & its Variations:-  Ficat & Arlet proposed creating an 8 to 10 mm dia core track & this became a “standard”  Recently some authors have suggested that the same effect of standard core can be achieved by producing Multiple Smaller Core Tracks of 3-mm dia range. This can be done percutaneously & theoretically # risk & shortens the operative time & morbidity  Steinberg et al proposed making Smaller Angled Core Tracks into the Necrotic Segment from the Central Core Canal
  • 80. Core Decompression Postoperative Management  The lateral cortical window produces a stress riser in the proximal femur So Protect the patient from unprotected weightbearing for the first 6 weeks  Reported incidence of # with core decompression is <1% & has almost always been associated with either a fall or failure to use protective devices (crutches or a walker) in the first 6 weeks
  • 81. Bone Grafting Procedures  Bone grafting procedures are a group of joint preserving techniques that involve the removal of the diseased femoral head segment, f/b its replacement with 1or more of a variety of bone graft options  These are most valuable in treating patients with Stage I & II disease
  • 82. Bone Grafting Procedures Techniques:-  Grafting Through Lateral Core Track  Grafting Through Femoral Neck Window  Grafting Through Articular Surface Window
  • 84. Grafting Through Lateral Core Track Advantages:-  Simple technique  Minimal Invasiveness  Avoidance of surgical dislocation of the hip  Low Complication Rate  Can be performed bilaterally under one anesthetic 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 #
  • 85. Grafting Through Femoral Neck Window  Watson-Jones or Smith-Peterson approach is used  A window is created to expose the anterior femoral neck, at the level of the junction of the femoral head & neck  When Combined with a Bone Grafting procedure,refered as the “light bulb” procedure.  Advantage is the improved access to the necrotic femoral head segment & the avoidance of direct iatrogenic cartilage damage  Disadvantage is the creation of a cortical defect in the femoral neck, which raises the risk of fracture
  • 86. Grafting Through Articular SurfaceWindow  The 3rd method of accessing the necrotic segment of the femoral head is known as the “Trapdoor” approach  With this method, the hip is surgically dislocated using a technique aimed at preserving the blood supply to the femoral head & neck  Once exposed, a “trapdoor” window is made in the femoral head cartilage to access the diseased subchondral bone  When combined with a bone grafting procedure, refered as the “Trapdoor” Procedure  Advantage : Exposure allows a direct evaluation of the cartilage surface & underlying diseased femoral head segment & allows for precise bone graft placement.  Disadvantage : Demanding technical nature Iatrogenic cartilage damage & osteonecrosis
  • 87. Grafting Through Articular SurfaceWindow
  • 88. Types of Bone Grafts Nonvascularized Grafts Vascularized Grafts  Nonvascularized cortical 2. Local pedicled grafts,which bone grafts are typically do not require microvascular prepared as several struts that provide structural reanastomosis support under the articular eg :Muscle-pedicle bone grafts surface within the evacuated Vascularized pedicle bone segment grafts  This construct is often augmented with cancellous 6. Free vascularized grafts, bone graft in an effort to which require a improve its osteoconductive microvascular and/or osteoinductive reanastomosis. properties eg: Free vascularized fibula graft
  • 90. Muscle-Pedicle Bone Grafts  Baksi et al (1991) => results in treating 68 hips with a variety of muscle-pedicle bone grafts  The preferred techniques were the tensor fascia lata-iliac crest graft anteriorly & the quadratus femoris posteriorly.  Of note, 82% of the hips treated in the series demonstrated some degree of collapse  At a mean follow-up of 7 years, there were good to excellent results in 83% of cases
  • 92. The harvested fibula with marbleized muscle attached confirming an extraperiosteal dissection. The peroneal artery & two accompanying veins
  • 93. Proximal Femoral Osteotomies  The main rationale proposed for the efficacy of osteotomies is the biomechanical effect of moving the collapsed/necrotic segment of the femoral head from the principal weight-bearing area of the hip to an area that bears less/no direct weight and to allow weight-bearing contact to now happen in an area of relatively normal bone and cartilage
  • 94. Proximal Femoral Osteotomies Categories:-  Valgus or varus osteotomies usually combined with flexion or extension  Transtrochanteric rotational osteotomies
  • 95. Proximal Femoral Osteotomies Indications:-  For varus or valgus osteotomies depend on the location & size of the lesion  Osteotomies may be used for both precollapse & postcollapse without notable acetabular involvement
  • 96. 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
  • 97. VALGUS OSTEOTOMY WITH FLEXION AND BONE GRAFTING
  • 98. VARUS OSTEOTOMY WITH FLEXION OR EXTENSION
  • 99. ROTATIONAL OSTEOTOMIES • Sugioka first reported a transtrochanteric transposition osteotomy with anterior rotation of the head and neck of the femur
  • 100. ROTATIONAL OSTEOTOMY before rotation After rotation 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
  • 102. Hip Resurfacing Procedures Femoral & Acetabular Surface Replacement & Hemi- Surface Replacement for Osteonecrosis of the Hip Indications :-  Later stages of osteonecrosis (University of Pennsylvania Stage III–VI)  > 30% femoral head involvement
  • 103. Metal-on Polyethylene Resurfacing  Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971) independently were the first to perform metal-on polyethylene resurfacing  Townley introduced a total articular resurfacing arthroplasty (TARA; Depuy, Warsaw,IN) that resurfaced the femoral head with a metal component while replacing the articulating surface of the acetabulum with a thin, plastic shell inserted with cement  Metal-on-polyethylene resurfacing yielded unacceptably high failure rates. The polyethylene-induced osteolysis resulting from the mating of large metal femoral head components with thin diameter acetabular cups
  • 104. Metal-on-Metal Bearings  Reduces the incidence of long-term failure from aseptic loosening & osteolysis
  • 105. Total Hip Replacement  TOC for advanced osteonecrosis of the hip (University of Pennsylvania Stages IVB–VIC)  Excellent pain relief & functional improvements  More recent studies at intermediate follow up up to 10 years have demonstrated similar survivorship compared to total hip replacement for osteoarthrosis.
  • 106. Bhumika – Non Cemented THR
  • 107. Miscllaneous Procedures  FEMORAL ENDOPROSTHESIS  ARTHRODESIS  RESECTION ARTHROPLASTY  ACRYLIC CEMENT INJECTION
  • 108. Femoral Endoprosthesis  Initial changes are in the femoral head and not the acetabulum  Replacing the femoral head would also be more conservative than the additive procedure of acetabular reconstruction, allowing for later simple conversion to total hip arthroplasty
  • 109. Arthrodesis  Mostly a salvage procedure in contemporary orthopedics  In the patient with significant pain & disability & in whom nonsurgical T/t has failed with a contraindication to prosthetic replacement  Clinical success can be achieved as it may relieve hip pain  The recommended position is 0° to 5° of adduction, 25° to 30° of flexion & 0° to 15° of external rotation  Later revision to a THR has a significant complication rate with less functional outcome
  • 110. Resection Arthroplasty  T/t of last resort  Complete resection of the head & neck of the femur  Can achieve a good range of pain-free motion & will be able to function reasonably well for most activities of daily living  The use of a shoe lift is generally necessary as a result of the shortening of the extremity, which averages approximately 1.5 inches  There will be a noticeable abductor lurch & patients will require some form of assistive device for ambulation  Indication:- patient with severe pain and disability who is not a
  • 111. Acrylic Cement Injection  Debriding the necrotic zone then elevating & supporting the collapsed segment by the injection of cement  Wood and coworkers reported on very preliminary results 21 of 20 cases  All patients realized immediate pain relief with improved hip scores, with 3 patients undergoing early conversion to total hip arthroplasty  Relatively invasive but may have the advantage of maintaining femoral head congruity  Long-term results with perhaps a randomized controlled series will be necessary if this is a viable alternative to reconstructive surgery
  • 112. POROUS TANTALUM ROD INSERTION  A novel approach in T/t of stage I & II precollapse osteonecrosis  This rod functions analogously to a Cortical Strut Graft allowing structural & osteoconductive properties
  • 113. POROUS TANTALUM ROD INSERTION
  • 114. Sir Astley Paston COOPER 1768–1841 “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 knowledge. Observations on diseased living, examinations of the dead & experiments upon living animals are the only sources of true knowledge.”

Notes de l'éditeur

  1. because they occur within an area of dead bone
  2. delicate, sclerotic, raylike branchings emanating in a radial fashion from the central dense band
  3. Axial CT scan of a patient with avascular necrosis of the femoral head (same patient as Images 8-12) shows clumping and distortion of the central trabeculae representing the asterisk sign (arrowhead) and an adjacent low-density region (arrow) representing the reparative zone.
  4. To minimize the chance of fracture, place patients on crutches until there is clinical, radiographic, and MRI evidence of resolution. This may require 4–6 months. This condition affects and these patients have no associated risk factors as in osteonecrosis. In women, it classically develops, and the incidence of fracture is greater than in men. The disease rarely involves both hips at the same time. Occasionally, the opposite hip is affected months or years later. It is difficult to make a definitive diagnosis on the basis of standard radiographs because the only abnormality is mild osteopenia of the femoral head and neck.
  5. The improvement observed in hips treated with CD plus demineralized bone matrix (DBM), although not statistically significant, may be clinically significant.
  6. (citric acid, sodium citrate, and dextrose).
  7. This is because symptomatic ON is characterized by an elevated intramedullary pressure &amp; creating a hole in the cortex &amp; cancellous bone of the proximal femur has been observed to immediately reduce that pressure (personal observation).