AVASCULAR NECROSIS AVASCULAR NECROSIS FEMORAL HEADFEMORAL HEAD

By :

Dr. Rajat MalotDr. Rajat Malot

Assistant ProfessorAssistant Professor

SMS Medical college SMS Medical college

JaipurJaipur

How to Approach a patient with Hip Pain

• Detailed History :

Trauma ,Drug intake,Any other joint involvement,Constitutional symptoms,Any metabolic or endrocrine disorder

• Pain : Exact site, mode of onset,Radiation

• Age

• Gait : Antalgic /Trendelenberg

Anterior Hip pain or Groin pain

Lateral pain or Trochanteric pain

Posterior hip pain

Rule out: hip fracture, septic joint, and avascular necrosis

Other causes:OA, RA, iliopectineal bursitis

Rule out: hip fracture, bone tumor, referred pain from lumbar disc herniation

Other causes: trochanteric bursitis,OA, radiating fromlumbar disc or facet disease

Rule out: sciatic nerve irritation ,sacroiliitis due to spondyloarthropathy, lumbardisc or facet disease

Other causes:muscle strain

No distinguishing Clinical Features/ High index of suspicion

Asymptomatic Pain gradual & insidious in nature

Range Of Motion (ROM) ; patient may walk with a limp

Radiographic findings may appear after a delay of several months to years following the onset of symptoms

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Focal over the groin / hip or it may radiate to the buttocks, anteromedial thigh or knee

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

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

Worsened by coughingcoughing & at nightnight

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

A ClickClick may be heard when the patient rises from a sitting position or on external rotation of an abducted hip

Characteristics Of PainCharacteristics Of Pain

ROM may be diminished, especially after collapse of the collapse of the femoral headfemoral head

ROM may be limited, especially in flexion, abduction & internal flexion, abduction & internal rotationrotation

GaitGait :- Patients may walk with a limp.

The Trendelenburg signThe Trendelenburg sign may be PositivePositive

To be diagnosed at an early stage, high index of suspicion, especially true with U/L involvement because of the high risk of the dev. of AVN in the C/L Hip

Range Of MotionRange Of Motion

BLOOD SUPPLY OF FEMORAL HEADBLOOD SUPPLY OF FEMORAL HEAD The principal sources are the Lateral Epiphyseal Vessels Lateral Epiphyseal Vessels

(LEVs). (LEVs).

LEVs Posterior Superior Retinacular Vessels (PSVs)

Medial Femoral Circumflex Artery Profunda-

Femoris Artery.

LEV supplies lateral and central thirds of the femoral head When patent, the Artery of Ligamentum Teres(ALT)Artery of Ligamentum Teres(ALT) supplies

medial third of the femoral head.

Branches of LEVs & ALT anastomose at the junction of central & medial 1/3 of the femoral head

BLOOD SUPPLY OF FEMORAL HEADBLOOD SUPPLY OF FEMORAL HEAD

lateral circumflex A.

Medial circumflex A.

Blood Supply in Paediatric Age Gp.Blood Supply in Paediatric Age Gp.

Till 4-7 years of age4-7 years of age, the vascular anatomy in a transitional stage of development.

The ALT does not penetrate the epiphysis of the femoral head until 9 or 10 years of age.

The Medial Circumflex Artery (br.of Profunda Femoris Artery), penetrates into the femoral proximal metaphysis but is prevented from passing into the femoral epiphysis by the growth plate.

The blood supply to the femoral head is especially vulnerable during this time.

AVN HISTORYAVN HISTORY

KonigKonig (1888) => first described the condition coined the term Osteochondritis Dissecans

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

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

PietrograndiPietrograndi (1957) => AVN d/t Steroid therapy Steroid therapy

AVASCULAR NECROSISAVASCULAR NECROSIS Misnomer; Basically it is Osteonecrosis (dead bone)

Also c/a Osteochondritis Dissecans Osteochondritis Dissecans / / Chandler’s DiseaseChandler’s Disease

in Young Adults

60% => B/L

One of the most challenging problems faced by orthopaedic surgeons.

Annual Incidence in US 15,000-20,000 Estimated Burden => 10% of total THR’s d/t AVN (50,000) 25% of total expenditure on AVN (1 billion $)

M/c affects => Femoral HeadFemoral Head

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

Incidence d/t Steroid usage & Trauma

AVN only occurs in FATTY MARROWFATTY MARROW, which contains a Sparse vascular supplySparse vascular supply. In contrast to Hematopoietic marrow which has a rich blood supply

AVASCULAR NECROSISAVASCULAR NECROSIS

NO……………….NO……………….

Fat cells become smaller in elderly persons. The space between fat cells fills with a loose reticulum and mucoid fluid, which are resistant to AVN.

This condition is termed Gelatinous marrowGelatinous marrow.. Even in the presence of increased intramedullary pressure, interstitial fluid is

able to escape into the blood vessels, leaving the spaces free to absorb additional fluid.

Does Elderly Persons are at Does Elderly Persons are at

increased risk for AVNincreased risk for AVN?????????

ETIOLOGYETIOLOGY

IntravascularIntravascular

Extraosseous Extraosseous vascular factorvascular factor I. Arterial factors

Intraosseous Intraosseous vascular factorsvascular factors I. Arterial factors II. Venous factors

ExtravascularExtravascular

Intraosseous Intraosseous factorsfactors

Capsular factors

Extraosseous Vascular FactorsExtraosseous Vascular Factors Arterial FactorsArterial Factors

Most important

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

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

Intraosseous Vascular FactorsIntraosseous Vascular Factors

Arterial FactorsArterial Factors

Circulating microemboliCirculating microemboli that block the microcirculation of the femoral head

In Conditions like-

1. Fat emboli (hyperlipidemia associated with alcoholism) 2. steroid therapy3. SCD4. nitrogen bubbles in decompression sickness

Enlargement of intramedullary fat cells or fat-loading osteocytes causes the cells to expand; this may be the most significant factor l/t obstruction of venous drainageobstruction of venous drainage

Reducing venous outflow & causing stasis

S/i Caisson disease & SCD

Intraosseous Vascular FactorsIntraosseous Vascular Factors

Venous FactorsVenous Factors

Ficat et alFicat et al demonstrated increased bone marrow demonstrated increased bone marrow pressure in the femoral necks of a large number pressure in the femoral necks of a large number of patients with avascular necrosis of the femoral of patients with avascular necrosis of the femoral head (AVN).head (AVN).

Extravascular FactorsExtravascular Factors

Intraosseous FactorsIntraosseous Factors

Alcohol & SteroidAlcohol & Steroid

Direct toxic metabolic Direct toxic metabolic effect on osteogenic cellseffect on osteogenic cells

Steroid Steroid

Hypertrophy of Fat cellsHypertrophy of Fat cellsGaucher cells & Inflammatory cells Gaucher cells & Inflammatory cells

Encroach on intraosseous capillaries Encroach on intraosseous capillaries

Intramedullary circulation Intramedullary circulation

Compartment syndromeCompartment syndrome

Trauma, Infection & ArthritisTrauma, Infection & Arthritis

Effusions within the Hip jointEffusions within the Hip joint

Intracapsular PressureIntracapsular Pressure

Tamponade of the LEVs Tamponade of the LEVs

Extravascular FactorsExtravascular Factors

Capsular FactorsCapsular Factors

SEQUELAE OF AVNSEQUELAE OF AVN

Minimal AVNMinimal AVN

Avascular area is Avascular area is small & is not adjacent small & is not adjacent to an articular surface.to an articular surface.

Patient may be Patient may be AsymptomaticAsymptomatic

Healing may occur Healing may occur spontaneously or the spontaneously or the disease may remain disease may remain undetected undetected

More Severe AVNMore Severe AVN

Once AVN develops, repair Once AVN develops, repair Begins at the interface b/w Begins at the interface b/w viable bone & necrotic bone viable bone & necrotic bone

Ineffective ResorptionIneffective Resorption of of dead bone within the necrotic dead bone within the necrotic focus is the rule. focus is the rule. Mixed sclerotic and cysticMixed sclerotic and cystic appearance on radiographs.appearance on radiographs.

MECHANICAL FAILUREMECHANICAL FAILURE

Non-healing Micro# in Non-healing Micro# in Subchondral regionSubchondral region

DDiffuse Subchondral #

X-Ray :- X-Ray :- CrescentCrescent

Progressive Wt. Bearing Progressive Wt. Bearing

Degenerative joint disease (DJD) & Joint DissolutionDegenerative joint disease (DJD) & Joint Dissolution

SEQUELAE OF AVNSEQUELAE OF AVN

Collapse of the Collapse of the Articular CartilageArticular Cartilage

Vicious CycleVicious Cycle

CAUSESCAUSES Trauma Trauma Alcohol consumptionAlcohol consumption Corticosteroid intakeCorticosteroid intake Hypercortisolism Cushing disease Hemoglobinopathies (SCD;Hb S/C;Polycythemia) Caisson disease

(Dysbaric osteonecrosis) Pancreatitis Neoplasms CRF Hemodialysis Cigarette smoking Collagen Vascular dis. SLE

Gout and hyperuricemia Hypercholesterolemia Hypercoagulable states Hyperlipidemia Hyperparathyroidism Intravascular coagulation Organ transplantation Pregnancy Congenital dislocation Hip Ehlers-Danlos synd Heredity dysostosis Legg-Calvé-Perthes dis Fabry disease Gaucher disease Giant cell arteritis Thrombophlebitis Idiopathic

Mechanism of Development of AVN d/t TraumaMechanism of Development of AVN d/t Trauma

Steroid (35-40%)Steroid (35-40%)

6 mechanisms 1. Fat Emboli from the liver => Occlusion of Small VesselsOcclusion of Small Vessels 2. Steroid Intramedullary Fat Cells Size without an equivalent

compensatory loss of trabecular & cortical bone => Intraosseous Intraosseous pressurepressure

3. Fat Emboli FFAs Toxic to vascular endo. Intravascular CoagulationIntravascular Coagulation

4. Synthesis of Polyclonal Antithyroid Hormone Receptor Alpha-Ab

Angiogenesis Proteolytic ActivityProteolytic Activity5. A direct toxic effect occurs on osteogenic cells6. Hematopoietic Marrow Fatty Marrow

> 20 mg & 6 Wks => Risk

CAUSESCAUSES

Hydrolysis

(-)

Steroid Induced Blood Flow

Investigations Investigations

MRIMRI SPECT SPECT CT ScanCT Scan Plain X-RayPlain X-Ray Most SensitiveMost Sensitive

1.5-T magnet1.5-T magnet 88% sensitivity 100% specificity

94% accuracy  (Beltran et al)(Beltran et al)

Indispensable for Accurate StagingAccurate Staging

of AVN because images clearly depict1. Size of the lesion2. Gross estimates of

stage

Reflects Vascular IntegrityVascular Integrity

Avascular Focus may be demonstrated Early in Early in DiseaseDisease (MRI Contrast)(MRI Contrast)

85% sensitivity (Collier)(Collier)

Triple-Head High- resolution SPECT Sensitivity 97% (Lee et al)(Lee et al)

For Extent of InvolvementExtent of Involvement e.g. Subchondral Lucencies & Sclerosis during Reparative stage

Enables detection of subchondral or cancellous # & collapse

Unable to detect disease of stage 0 or 1

Helpful in assessing flattening flattening of the Femoral Head & asso.of the Femoral Head & asso. Degen. changes Degen. changes

Radiology- sequential Changes

• Crescent Sign• Osteoporosis• Sclerosis• Cystic changes• Loss of spherical weight bearing

dome• Partial collapse of head• Secondary Osteoarthritis

Classic Findings:-Classic Findings:- look for focal lesion in the look for focal lesion in the anterosuperior portion of femoral head that is well anterosuperior portion of femoral head that is well demarcated but is inhomogeneousdemarcated but is inhomogeneous

T1 imagesT1 images => low signal intensity => low signal intensity

T2 imagesT2 images => => double line sign =>double line sign => classic sign of AVN, classic sign of AVN, made up of 2 concentric low and high signal bandsmade up of 2 concentric low and high signal bands

high-signal-intensity line may represent hypervascular high-signal-intensity line may represent hypervascular granulation tissuegranulation tissue

MRI FindingsMRI Findings

MRI T1 image

signal from ischemic marrow

• Single band like area of low signal intensity.

• 100% sensitivity

• 98% specificity

Double Line sign – T2 image

• A second high signal intensity seen within the line seen on T1 images.

• Represent hyper vascular granulation tissue

Early

FEMORAL HEAD CHANGES

CORONAL T2-WEIGHTED MRI CORONAL T2-WEIGHTED MRI

Axial CT: Patient without AVN of the Femoral HeadAxial CT: Patient without AVN of the Femoral Head

Prominent & Thickened but Normal Trabeculae

ASTERISK SIGNASTERISK SIGN

TRANSIENT OSTEOPOROSIS OF THE HIP TRANSIENT OSTEOPOROSIS OF THE HIP (TOH) (TOH) D/D:-D/D:-

No findings of bone infarction or repair, which are the hallmarks of No findings of bone infarction or repair, which are the hallmarks of osteonecrosisosteonecrosis

The pathologic picture is primarily one of marrow edema, hence also The pathologic picture is primarily one of marrow edema, hence also referred to as referred to as Bone marrow edema syndrome (BMES) Bone marrow edema syndrome (BMES)

Clinically, pain is usually more sudden, severeClinically, pain is usually more sudden, severe

in females esp.during 3in females esp.during 3rdrd trimester of pregnancy trimester of pregnancy

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

TOH is usually self-limited.T/t is protected weight bearing to prevent #. TOH is usually self-limited.T/t is protected weight bearing to prevent #. Infrequently, core decompression may be indicated if a patient has an Infrequently, core decompression may be indicated if a patient has an inordinate amount of pain or if the diagnosis is in doubt.inordinate amount of pain or if the diagnosis is in doubt.

A diffuse low signal intensity in the T1-weighted image and a high intensity A diffuse low signal intensity in the T1-weighted image and a high intensity in the T2-weighted imagein the T2-weighted image

• In the 1960s, Arlet & Ficat in France

described a 3-part staging system & in the

1970s a 4th stage was added

CLASSIFICATION & STAGINGCLASSIFICATION & STAGING

Paul FICAT

This form is perhaps the one This form is perhaps the one most widely usedmost widely used now, despite the now, despite the fact that a stage 0 & a transitional stage were added laterfact that a stage 0 & a transitional stage were added later

FICAT’s scientific works spanned a wide range of topics from ligament instability to osteoarthrosis & from chondromalacia patellae to AVN

To each area he brought not only the perception of the clinician but also the ability to see with the eyes of the physiologist, the microscopist & even the electron microscopist

He was one of the few orthopedic clinicians with the ability to “see” problems at the cellular and subcellular level

Paul FICAT1917-19861917-1986

Stage Clinical Features Radiographs

0 Preclinical 0 0

1 Preradiographic + 0

2 Precollapse + Diffuse Porosis,

Sclerosis, Cysts

3 Early Collapse ++ Crescent Sign Certain Sequestrum,

Joint Space Normal

4 Osteoarthritis +++ Flattened Contour Decreased Joint Space Collapse of Head

Ficat & Arlet ClassificationFicat & Arlet Classificationt Stages of Bone Necrosis

A major disadvantage was that it A major disadvantage was that it didn’t include any measurement of didn’t include any measurement of

lesion size or articular surface lesion size or articular surface involvement..involvement..

Stage 1Stage 1 : Asymptomatic, mottled increased density of : Asymptomatic, mottled increased density of femoral headfemoral head

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

Stage 3Stage 3 : Intermittent pains, : Intermittent pains, Crescent signCrescent sign in frog lateral in frog lateral viewview

Stage 4Stage 4 : Painful limb & flattening of femoral head : Painful limb & flattening of femoral head

Stage 5Stage 5 : Symptoms & signs of degenerative arthritis : Symptoms & signs of degenerative arthritis

Stage 6Stage 6 : Severe degenerative arthritis : Severe degenerative arthritis

Radiographic StagingRadiographic Staging(Marcus et al 1973)(Marcus et al 1973)

Stage 0 – 3Stage 0 – 3 :- Same as Ficat Arlet :- Same as Ficat Arlet Stage 4Stage 4 :- Flattening of femoral head :- Flattening of femoral head

Stage 5Stage 5 :- Joint narrowing with or without acetabular :- Joint narrowing with or without acetabular involvementinvolvement

Stage 6Stage 6 :- Advanced degenerative changes :- Advanced degenerative changes

These stages were further divided intoThese stages were further divided into Mild, Moderate & SevereMild, Moderate & Severe

Steinberg et al (1995) Modified Steinberg et al (1995) Modified Ficat & Arlet ClassificationFicat & Arlet Classification

1974, Kerboul et alKerboul et al noted that the results of osteotomies performed for osteonecrosis depended on both the location & the location & the extent of the lesionthe extent of the lesion

This latter was expressed in degrees after measuring the arc of

the articular surface involved as seen on both AP and lateral radiographs of the femoral head.

Similar observations were reported by Wagner and Zeiler , Wagner and Zeiler , Sugioka et al. and Koo and Kim Sugioka et al. and Koo and Kim

Kerboul:- combined necrotic angle – AP LAT

0 Normal or nondiagnostic x-ray, bone scan, and MRI0 Normal or nondiagnostic x-ray, bone scan, and MRI

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

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

III Subchondral collapse (‘Crescent Sign’) without III Subchondral collapse (‘Crescent Sign’) without flatteningflattening

A. Mild (15% of articular surface)A. Mild (15% of articular surface) B. Moderate (15%–30%)B. Moderate (15%–30%) C. Severe (30%)C. Severe (30%)

University Of Pennsylvania University Of Pennsylvania Classification of OsteonecrosisClassification of Osteonecrosis

IV Flattening of femoral headIV Flattening of femoral head A. Mild (15% of surface and 2 mm depression)A. Mild (15% of surface and 2 mm depression) B. Moderate (15%–30% of surface or 2–4 mm depression)B. Moderate (15%–30% of surface or 2–4 mm depression) C. Severe (30% of surface or 4 mm depression)C. Severe (30% of surface or 4 mm depression) V Joint narrowing and/or acetabular changesV Joint narrowing and/or acetabular changes A. Mild (Average of femoral head involvement as determined in stage IV & A. Mild (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)estimated acetabular involvement) B. Moderate (Average of femoral head involvement as determined in stage B. Moderate (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)IV & estimated acetabular involvement) C. Severe (Average of femoral head involvement as determined in stage IV C. Severe (Average of femoral head involvement as determined in stage IV & estimated acetabular involvement)& estimated acetabular involvement)

VI Advanced degenerative changesVI Advanced degenerative changes

From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head: From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head: Results of core decompression and grafting with electrical stimulationResults of core decompression and grafting with electrical stimulation

University Of Pennsylvania University Of Pennsylvania Classification of OsteonecrosisClassification of Osteonecrosis

1991, The Committee on Nomenclature & Staging of the Association Research Circulation Osseous (ARCO) endorsed the staging system developed at the University of Pennsylvania in the early 1980s

1992, location of the lesion, as described in the Japanese system , was added

1993, stages III & IV were combined, as were stages V & VI

ClassClass T1T1 T2T2 DefinitionDefinition

AA Bright Intermediate Fat signal

BB Bright Bright Blood signal

CC Intermediate Bright Fluid or edema signal

DD Dark Dark Fibrosis signal

Mitchell’s MRI StagingMitchell’s MRI Staging

Specific CriteriaSpecific Criteria Collapse of femoral head

Subchondral radiolucent line

Anterolateral sequestrum

Bone scan showing a photopenic region surronded by area of increased density

Double band on T2-weighted image

Bone biopsy showing empty lacunae involving multiple adjacent trabeculae

Criteria For DiagnosisCriteria For Diagnosis(Current Concept JBJS Mont & Hungerford)(Current Concept JBJS Mont & Hungerford)

Non specific criteriaNon specific criteria Collapse of femoral head with narrowing of joint space

Mottled ,cystic & sclerotic pattern in head

MRI showing changes in bone marrow

Painful movements of hip with normal X ray

H/O of alcohol & steroid intake

Non specific but abnormal biopsy , edema /fibrois

PreservePreserve rather than Replacing Femoral Head & Cartilage

Early InterventionEarly Intervention has favorable impact on the disease prognosis irrespective of T/t modality used

AIM OF TREATMENTAIM OF TREATMENT

Indications:-Indications:-

Small, Asymptomatic lesionsSmall, Asymptomatic lesions

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

When Sx is contraindicated or declinedWhen Sx is contraindicated or declined

Buying time until arthroplasty is neededBuying time until arthroplasty is needed

Medical ManagementMedical Management

PROTECTED WEIGHT BEARINGPROTECTED WEIGHT BEARING Protect the involved area from excessive stress by using some form of limited Protect the involved area from excessive stress by using some form of limited

weight bearing. weight bearing. Canes or even crutchesCanes or even crutches are frequently prescribed are frequently prescribed Don’t alter the natural course of the disorderDon’t alter the natural course of the disorder

INDICATIONS:-INDICATIONS:-

AlternativeAlternative to surgical management to surgical management Small, Asymptomatic lesionsSmall, Asymptomatic lesions low weight bearing area, such as the low weight bearing area, such as the medial aspectmedial aspect of the femoral head of the femoral head

Poor medical conditionPoor medical condition

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

Most important role :Most important role :relatively advanced stages of osteonecrosisrelatively advanced stages of osteonecrosis. . Cane or Crutches can diminish symptoms and improve function considerably Cane or Crutches can diminish symptoms and improve function considerably

until such time as a reconstructive procedure is indicateduntil such time as a reconstructive procedure is indicated

Glueck & colleaguesGlueck & colleagues => Incidence of => Incidence of osteonecrosis in association with certain osteonecrosis in association with certain Coagulopathies & HyperlipidmiasCoagulopathies & Hyperlipidmias

Stanozolol anabolic androgenic steroidStanozolol anabolic androgenic steroid potenial potenial means of treating AVN associated with means of treating AVN associated with Coagulopathies & HyperlipidemiasCoagulopathies & Hyperlipidemias

Motomura et alMotomura et al => Incidence of => Incidence of SSteroid-inducedteroid-induced osteonecrosis in rabbits using a combination of osteonecrosis in rabbits using a combination of Warfarin & Probucol (Lipid Lowering Agents)Warfarin & Probucol (Lipid Lowering Agents)

ENAXOPARINENAXOPARIN adminstered for adminstered for 12 weeks12 weeks was was found to prevent radiographic found to prevent radiographic Progression of Progression of Stage 1 and Stage 2 idiopathicStage 1 and Stage 2 idiopathic osteonecrosis of osteonecrosis of the femoral head at 2 year follow upthe femoral head at 2 year follow up

GauthierGauthier => 95%-100% of transplant patients => 95%-100% of transplant patients who were treated with who were treated with Calcium Channel Calcium Channel BlockersBlockers experienced complete relief of experienced complete relief of Bone Bone Pain SyndromePain Syndrome

I.V.I.V. ILIOPROST ILIOPROST, a Vasoactive Prostacyclin , a Vasoactive Prostacyclin analogue showed significant improvements in analogue showed significant improvements in patients with patients with Bone Marrow Edema Syndrome & Bone Marrow Edema Syndrome & OsteonecrosisOsteonecrosis

Oral NifedipineOral Nifedipine => Relief of bone pain reported => Relief of bone pain reported in a small series of patients with Osteonecrosisin a small series of patients with Osteonecrosis

AlendronateAlendronate :- In a prospective study of 100 hips with :- In a prospective study of 100 hips with osteonecrosis, osteonecrosis, Agarwal et alAgarwal et al reported that l/t significant reported that l/t significant improvement in Pain & Disability scoresimprovement in Pain & Disability scores

Marrow edema Marrow edema improvedimproved on MRI & plain films were unchanged on MRI & plain films were unchanged or progressed one gradeor progressed one grade

In a prospective randomized study of 40 patients with stage II In a prospective randomized study of 40 patients with stage II or III osteonecrosis & minimum 2-year follow-up, only 2 of 29 or III osteonecrosis & minimum 2-year follow-up, only 2 of 29 patients taking alendronate experienced collapse of the femoral patients taking alendronate experienced collapse of the femoral head, whereas 19 of 25 heads in the control group collapsed head, whereas 19 of 25 heads in the control group collapsed

BisphosphonatesBisphosphonates => reportedly causing => reportedly causing Osteonecrosis of the JawOsteonecrosis of the Jaw , so should be used , so should be used cautiouslycautiously

PuerarinPuerarin :- :- An extract of the kudzu vineAn extract of the kudzu vine , , is purported to is purported to Cholesterol, Platelet Aggregation & cause Vasodilation.Cholesterol, Platelet Aggregation & cause Vasodilation.

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

No data on the use of puerarin for osteonecrosis in humans No data on the use of puerarin for osteonecrosis in humans are availableare available

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

Mechanisms Of Action:-Mechanisms Of Action:-

1.1. Local control of inflammationLocal control of inflammation

2.2. Enhances repair activity & healing process by Enhances repair activity & healing process by stimulating neovascularisation & new bone stimulating neovascularisation & new bone formation.formation.

Electric, Electromagnetic & Acoustic T/t

Radiographic progression in Ficat stage II . Hips treated with core decompression (CD) plus pulsed electromagnet fields (PEMF) exhibit 33% less radiographic

progression than hips treated with CD alone (P 0.04)

There are only 2 papers in PubmedThere are only 2 papers in Pubmed

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

At a mean of 25 months, At a mean of 25 months, 79%79% of the shock-wave group of the shock-wave group

had improved had improved Harris Hip ScoresHarris Hip Scores compared with compared with 29%29% of of the group treated with non-vascularized fibular graftingthe group treated with non-vascularized fibular grafting

Extracorporeal Shockwave TherapyExtracorporeal Shockwave Therapy

HBO improves oxygenation, reduces oedema & induces HBO improves oxygenation, reduces oedema & induces angioneogenesis, a reduction in intra osseous pressure angioneogenesis, a reduction in intra osseous pressure & improvement in microcirculation& improvement in microcirculation

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

They reported that They reported that 13 of the 1613 of the 16 femoral heads femoral heads subsequently appeared normal on MRI after this T/tsubsequently appeared normal on MRI after this T/t

Hyperbaric oxygen (HBO)Hyperbaric oxygen (HBO)

Supplemented with Core DecompressionSupplemented with Core Decompression

Principle:-Principle:-

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

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

Bone Marrow InjectionsBone Marrow Injections

Bone Marrow InjectionsBone Marrow InjectionsTechniqueTechnique

Usual site => Usual site => Anterior Iliac CrestAnterior Iliac Crest

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

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

Aspirates pooled in plastic bags Aspirates pooled in plastic bags containing an anticoagulant containing an anticoagulant solutionsolution

Filtered to remove fat aggregates & Filtered to remove fat aggregates & clotsclots

Trocar

Current Indications:-Current Indications:-

The best indications are hips The best indications are hips with osteonecrosis & with osteonecrosis & without collapsewithout collapse

In some patients who had Steinberg stage III In some patients who had Steinberg stage III

(subchondral crescent, no collapse), successful (subchondral crescent, no collapse), successful outcomes (no further surgery) have been obtained outcomes (no further surgery) have been obtained between 5 and 10 years. Therefore, between 5 and 10 years. Therefore, in selected in selected patients, even more advanced diseasepatients, even more advanced disease can be can be considered for core decompressionconsidered for core decompression

Bone Marrow InjectionsBone Marrow Injections

Bone Marrow InjectionsBone Marrow Injections

Surgical proceduresSurgical procedures

Joint PreservingJoint Preserving Joint ReplacingJoint Replacing Core Core Decompression Decompression

Various Various Nonvascularized & Nonvascularized & Vascularized Bone Vascularized Bone Grafting ProceduresGrafting Procedures

Osteotomy Osteotomy ProceduresProcedures

Total Hip Total Hip Arthroplasty Arthroplasty

Hip Resurfacing Hip Resurfacing ProceduresProcedures

Core DecompressionCore Decompression

Core Core decompression decompression was “discovered” was “discovered” by Paul Ficat & by Paul Ficat & Jacques Arlet in Jacques Arlet in the 1960sthe 1960s

Incidental Incidental discoverydiscovery

Indications:-Indications:-

Core decompression is effective for symptomatic relief in Core decompression is effective for symptomatic relief in nearly all stages in all patients who present with a nearly all stages in all patients who present with a painful painful hip secondary to ONhip secondary to ON d/t of intramedullary pressure done d/t of intramedullary pressure done by itby it

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

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

The larger the lesion, the less likely the patient is to have a The larger the lesion, the less likely the patient is to have a

successful outcome. successful outcome.

Core DecompressionCore Decompression

Standard Technique & its Variations:-Standard Technique & its Variations:- Ficat & ArletFicat & Arlet proposed creating an proposed creating an 8 to 10 mm dia core 8 to 10 mm dia core

tracktrack & this became a & this became a “standard” “standard”

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

Steinberg et alSteinberg et al proposed making proposed making Smaller Angled Core Smaller Angled Core Tracks into the Necrotic Segment from the Central Core Tracks into the Necrotic Segment from the Central Core CanalCanal

Core DecompressionCore Decompression

Postoperative ManagementPostoperative Management

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

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

Core DecompressionCore Decompression

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

These are most valuable in treating patients with These are most valuable in treating patients with Stage I & II Stage I & II diseasedisease

Bone Grafting ProceduresBone Grafting Procedures

Techniques:-Techniques:-

Grafting Through Lateral Core Track

Grafting Through Femoral Neck Window

Grafting Through Articular Surface Window

Bone Grafting ProceduresBone Grafting Procedures

Grafting Through Lateral Core TrackGrafting Through Lateral Core Track

Advantages:-Advantages:-

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

Disadvantages:-Disadvantages:-

Inability to directly visualize the joint surfaces Inexact nature of removing diseased bone & replacing it

with bone graft under fluoroscopic guidance Risk of postoperative #

Grafting Through Lateral Core TrackGrafting Through Lateral Core Track

Watson-Jones or Smith-Peterson approach Watson-Jones or Smith-Peterson approach is used is used

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

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

AdvantageAdvantage is the improved access to the is the improved access to the

necrotic femoral head segment & the necrotic femoral head segment & the avoidance of direct iatrogenic cartilage avoidance of direct iatrogenic cartilage damagedamage

DisadvantageDisadvantage is the creation of a cortical is the creation of a cortical defect in the femoral neck, which raises the defect in the femoral neck, which raises the risk of fracturerisk of fracture

Grafting Through Femoral Neck WindowGrafting Through Femoral Neck Window

The 3The 3rdrd method of accessing the necrotic segment of the femoral head is method of accessing the necrotic segment of the femoral head is known as the known as the “Trapdoor” approach“Trapdoor” approach

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

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

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

AdvantageAdvantage : Exposure allows a direct evaluation of the cartilage surface & : Exposure allows a direct evaluation of the cartilage surface &

underlying diseased femoral head segment & allows for underlying diseased femoral head segment & allows for precise bone graft placement. precise bone graft placement.

DisadvantageDisadvantage : Demanding technical nature : Demanding technical nature Iatrogenic cartilage damage & osteonecrosisIatrogenic cartilage damage & osteonecrosis Surgical dislocationSurgical dislocation

Grafting Through Articular SurfaceWindowGrafting Through Articular SurfaceWindow

Grafting Through Articular SurfaceWindowGrafting Through Articular SurfaceWindow

Nonvascularized GraftsNonvascularized Grafts Nonvascularized cortical Nonvascularized cortical

bone graftsbone grafts are typically are typically prepared as several struts prepared as several struts that provide structural that provide structural support under the articular support under the articular surface within the evacuated surface within the evacuated segmentsegment

This construct is often This construct is often augmented with cancellous augmented with cancellous bone graft in an effort to bone graft in an effort to improve its osteoconductive improve its osteoconductive and/or osteoinductive and/or osteoinductive propertiesproperties

Vascularized GraftsVascularized Grafts

1.1. Local pedicled grafts,which Local pedicled grafts,which do not require microvascular do not require microvascular reanastomosisreanastomosis

eg :eg :Muscle-pedicle bone grafts Muscle-pedicle bone grafts Vascularized pedicle bone Vascularized pedicle bone

graftsgrafts

2.2. Free vascularized grafts, Free vascularized grafts, which require a which require a microvascular microvascular reanastomosis.reanastomosis.

eg: eg: Free vascularized fibula Free vascularized fibula graftgraft

Types of Bone GraftsTypes of Bone Grafts

Muscle-Pedicle Bone GraftsMuscle-Pedicle Bone Grafts

Baksi et alBaksi et al (1991) (1991) => results in treating 68 hips => results in treating 68 hips with a variety of muscle-pedicle bone graftswith a variety of muscle-pedicle bone grafts

The preferred techniques were the The preferred techniques were the tensor fascia tensor fascia lata-iliac crest graft anteriorly & the quadratus lata-iliac crest graft anteriorly & the quadratus femoris posteriorly. femoris posteriorly.

Of note, 82% of the hips treated in the series Of note, 82% of the hips treated in the series demonstrated some degree of collapsedemonstrated some degree of collapse

At a mean follow-up of 7 years, there were good At a mean follow-up of 7 years, there were good to excellent results in 83% of casesto excellent results in 83% of cases

Muscle-Pedicle Bone GraftsMuscle-Pedicle Bone Grafts

The harvested fibula with marbleized muscle attached confirming an extraperiosteal dissection. The peroneal artery & two accompanying veins

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

Proximal Femoral OsteotomiesProximal Femoral Osteotomies

Categories:-Categories:-

Valgus or varus osteotomies usually Valgus or varus osteotomies usually combined with flexion or extensioncombined with flexion or extension

Transtrochanteric rotational osteotomiesTranstrochanteric rotational osteotomies

Proximal Femoral OsteotomiesProximal Femoral Osteotomies

Indications:-Indications:-

For varus or valgus osteotomies depend For varus or valgus osteotomies depend

on the location & size of the lesionon the location & size of the lesion

Osteotomies may be used for both Osteotomies may be used for both precollapse & postcollapse without notable precollapse & postcollapse without notable acetabular involvementacetabular involvement

Proximal Femoral OsteotomiesProximal Femoral Osteotomies

VALGUS OSTEOTOMY WITH FLEXION

• when the necrotic segment is located in the anterosuperior part of the femoral head with less than 20% posterior involvement.

• Optimal patient population would be those that are less than 45 years of age and are

not on steroids or chemotherapy

VALGUS OSTEOTOMY WITH FLEXION ANDVALGUS OSTEOTOMY WITH FLEXION ANDBONE GRAFTINGBONE GRAFTING

VARUS OSTEOTOMY WITH FLEXION OR VARUS OSTEOTOMY WITH FLEXION OR EXTENSIONEXTENSION

ROTATIONAL OSTEOTOMIES

• Sugioka first reported a transtrochanteric transposition osteotomy with anterior rotation of the head and neck of

the femur

Transposition of the necrotic focus to the ant. & inf. part of the femoral head away from the weight-bearing area as a result of the ant. rotation of the head

before rotationAfter rotation

ROTATIONAL OSTEOTOMYROTATIONAL OSTEOTOMY

ROTATIONAL OSTEOTOMYROTATIONAL OSTEOTOMY

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

Indications :-Indications :-

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

> 30% femoral head involvement> 30% femoral head involvement

Hip Resurfacing ProceduresHip Resurfacing Procedures

Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971)Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971) independently were the first to perform metal-on polyethylene independently were the first to perform metal-on polyethylene resurfacingresurfacing

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

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

Metal-on Polyethylene ResurfacingMetal-on Polyethylene Resurfacing

Reduces the Reduces the incidence of long-term incidence of long-term failure from aseptic failure from aseptic loosening & loosening & osteolysisosteolysis

Metal-on-Metal BearingsMetal-on-Metal Bearings

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

Excellent pain relief & functional improvementsExcellent pain relief & functional improvements

More recent studies at intermediate follow up up to 10 More recent studies at intermediate follow up up to 10 years have demonstrated similar survivorship compared years have demonstrated similar survivorship compared to total hip replacement for osteoarthrosis.to total hip replacement for osteoarthrosis.

Total Hip ReplacementTotal Hip Replacement

Bhumika – Non Cemented THR

FEMORAL ENDOPROSTHESISFEMORAL ENDOPROSTHESIS

ARTHRODESISARTHRODESIS

RESECTION ARTHROPLASTYRESECTION ARTHROPLASTY

ACRYLIC CEMENT INJECTIONACRYLIC CEMENT INJECTION

Miscllaneous ProceduresMiscllaneous Procedures

Initial changes are in the Initial changes are in the femoral head and not the femoral head and not the acetabulumacetabulum

Replacing the femoral Replacing the femoral head would also be more head would also be more conservative than the conservative than the additive procedure of additive procedure of acetabular reconstruction, acetabular reconstruction, allowing for later simple allowing for later simple conversion to total hip conversion to total hip arthroplastyarthroplasty

Femoral EndoprosthesisFemoral Endoprosthesis

Mostly a salvage procedure in contemporary orthopedicsMostly a salvage procedure in contemporary orthopedics

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

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

The recommended position is 0° to 5° of adduction, 25° to The recommended position is 0° to 5° of adduction, 25° to 30° of flexion & 0° to 15° of external rotation30° of flexion & 0° to 15° of external rotation

Later revision to a THR has a significant complication Later revision to a THR has a significant complication rate with less functional outcomerate with less functional outcome

Arthrodesis Arthrodesis

T/t of last resortT/t of last resort

Complete resection of the head & neck of the femurComplete resection of the head & neck of the femur Can achieve a good range of pain-free motion & will be able to Can achieve a good range of pain-free motion & will be able to

function reasonably well for most activities of daily livingfunction reasonably well for most activities of daily living

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

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

Indication:-Indication:- patient with severe pain and disability who is not a patient with severe pain and disability who is not a

suitable candidate for reconstructionsuitable candidate for reconstruction

Resection ArthroplastyResection Arthroplasty

Debriding the necrotic zone then elevating & supporting the Debriding the necrotic zone then elevating & supporting the collapsed segment by the injection of cementcollapsed segment by the injection of cement

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

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

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

Long-term results with perhaps a randomized controlled series Long-term results with perhaps a randomized controlled series will be necessary if this is a viable alternative to reconstructive will be necessary if this is a viable alternative to reconstructive surgerysurgery

Acrylic Cement InjectionAcrylic Cement Injection

POROUS TANTALUM ROD INSERTIONPOROUS TANTALUM ROD INSERTION

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

This rod functions analogously to a This rod functions analogously to a Cortical Strut GraftCortical Strut Graft allowing allowing structural & osteoconductive propertiesstructural & osteoconductive properties

POROUS TANTALUM ROD INSERTIONPOROUS TANTALUM ROD INSERTION

““Young medical men find it so much easier to speculate then to observe. Young medical men find it so much easier to speculate then to observe. Nothing is known to our profession by guess. There is no short road to Nothing is known to our profession by guess. There is no short road to

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

knowledgeknowledge.”.”

Sir Astley Paston COOPERSir Astley Paston COOPER 1768–18411768–1841

Thank you