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Avascular necrosis of hip

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  • 1. Avascular Necrosis – A practical approach Girish Yeotikar Arjun Wadhwani Vinod Naneria Choithram Hospital & Research Centre, Indore, India
  • 2. Osteonecrosis –AVN The death of cell components of bone & bone marrow from repeated interruptions or a single massive interruption of the blood supply to the bone.
  • 3. AVN – responsible for • 15,000 new cases of AVN/year • 10% THR in USA. • 10% undisplaced # neck Femur • 30% displaced # neck Femur • 10% Dislocation Hip
  • 4. Management protocol • Early diagnosis • Radiological evaluation • Rule out other causes • MRI • Quantification • Treatment algorithm
  • 5. Early Diagnosis – suspicion ? • High degree of suspicion in a patient C/o anterior HIP pain, especially with:- H/o Cortisone – For -- Skin, Eye, Liver, Asthma, RA, Weight gain, PID H/o Alcohol abuse Traumatic - # N/F, D/ of F, # Acetabulum Hemoglobinopathy – Sickle / Myelo-infiltrating Even with normal x-rays
  • 6. Radiology- sequential Changes • Crescent Sign • Osteoporosis • Sclerosis • Cystic changes • Loss of spherical weight bearing dome • Partial collapse of head • Secondary Osteoarthritis
  • 7. Magnetic Resonance Imaging • After radiological evaluation • Cases of Ant. Hip pain + nil / minimal X- ray changes, ask for MRI • Rule out other causes of AVN Sickle cell, RA, Gout, CRF,SLE & other collagen disorders.
  • 8. MRI - Findings • Bone Marrow edema • Double Line – Head in Head sign • Crescent sign • Collapse • Joint effusion • Involvement of actabulum • Status of other hip • Marrow infiltrating disease
  • 9. MRI T1 image •  signal from ischemic marrow • Single band like area of low signal intensity. • 100% sensitivity • 98% specificity
  • 10. Double Line sign – T2 image • A second high signal intensity seen within the line seen on T1 images. • Represent hyper vascular granulation tissue
  • 11. Pearls & pitfalls on MRI • Involve antero-lateral aspect. • Articular cartilage intact initially. • Sagittal images are more accurate. • Double line sign may be –ve in 20%. • Collapse correspond to Ficat 3. • TOH may be Subchondral femoral head stress fractures.
  • 12. Normal AVN TOH
  • 13. Diagnosis Early Stage Osteonecrosis Direct Risk Factors Associated Risk Factors Traumatic fracture / dislocation Corticosteroid use Sickle cell disease Alcohol abuse Radiation Tobacco abuse Chemotherapy SLE Myeloproliferative disorders Organ transplant Thalassemia Gastrointestinal disorder Caisson disease Pregnancy, Genetic inheritance, Coagulation deficiency
  • 14. Pathophysiology • Acute vascular interruption: • Fracture • Dislocation • Altered lipid metabolism: • Corticosteroids. • Alcohol • Intravascular coagulation: • Heamoglobinopathy, familial thrombophilia, hypercholesterolemia, allograft organ rejection,, infection, malignancy, or pregnancy.
  • 15. Time Line • Death of hematopoietic cells - Ischemic insult – Bone scan + 6 -12 hours • Death of Osteocytes 12- 48 hours • Bone scan becomes negative once remodeling occur. • MRI will become positive after 5 days due to death of fat cells, but it will remain positive till complete healing. • Focal MR abnormality and diffuse marrow edema can been by 6-8weeks Histology is the only method to confirm AVN Empty lacuna – dead osteocytes
  • 16. Preventive measures • Judicial use of steroids • Use of Statin in cases of short/long term high dosage of steroids. • Public awareness for avoiding drug for rapid weight gain and decrease libido (anabolic steroids). • Discourage excessive alcohol and smoking. • Patients at high risk informed about the possibility of AVN, & to report symptoms as soon as possible to facilitate early diagnosis and treatment.
  • 17. Pharmacological Agents • lipid-lowering agents, • Anticoagulants, Prostacyclin analogs, may work by inhibiting aggregation of platelets, thus enhancing blood flow to ischemic bone areas and potentially promoting healing. • Statins, is based on the association of high levels of blood lipids and an increased risk of the development of osteonecrosis. • Bisphosphonates to decrease osteoclastic activity and permit bone formation via the osteoblastic process.
  • 18. Pharmacological Agents • The clinical failure rates for the various pharmacological therapies have ranged from 0% to 10%. • In one of these studies, Pritchett reported that the prevalence of osteonecrosis was only 1% in patients who were receiving corticosteroid therapy and who received concurrent statin therapy. • While the results of the pharmacological studies appear promising, the reported results were limited to only short-term to midterm follow-up.
  • 19. Quantification of the damage • On radiological evaluation & MRI evaluation: • Disease is quantified:- • Site of involvement • Size of involvement • Type of involvement • Bone marrow edema • Cystic • Sclerotic • combination
  • 20. Staging / Grading --- too many • Ficat Radiological • Steinberg Quantification • Enneking's Stages of Osteonecrosis • Marcus and Enneking System • Japanese criteria Location • Sugioka Radiological • University Of Pennsylvania System • Association Research Classification Osseous Committee (ARCO)-- Combination
  • 21. Stage Clinical Features Radiographs • 0 Preclinical 0 0 • 1 Preradiographic + 0 • 2 Precollapse + Diffuse Porosis, Sclerosis, Cysts • Transition: Flattening, Crescent Sign • 3 Collapse ++ Broken Contour of Head Certain Sequestrum, Joint Space Normal • 4 Osteoarthritis +++ Flattened Contour Decreased Joint Space , Collapse of Head Ficat Stages of Bone Necrosis
  • 22. Association Research Circulation Osseous quantification
  • 23. Relationship with weight bearing dome
  • 24. Japanese Investigation Committee Type 1 – Line of Demarcation In relation to Wt.bearing Type 2- Partial Collapse Type 3 Cyst A- central B peripheral
  • 25. Kerboul:- combined necrotic angle – AP LAT
  • 26. Factors which affects decision : • Cause of AVN • Sickle • Post Traumatic / # / D / Non union • Post Radiation • Age • CRF • Staging / quantification • Cortisone • Alcohol • Available technology • Cost of Treatment
  • 27. Mont and Hungerford JBJS 77A: 459-474,1995. • Meta analysis of the literature - 21 studies involving 819 hips , average follow-up 34 months, all treated non-operatively (various protocols of weight bearing status) • Rates of preservation of the femoral head: Stage 1 35% Stage 2 31% Stage 3 13% Natural History
  • 28. • Rates of preservation of the femoral head: Core Decomp. No Rx Stage 1 84% 35% Stage 2 65% 31% Stage 3 47% 13% Core decompression Statistics
  • 29. Stulberg et al CORR 186: 137-153, 1991 Randomised prospective study, 55 hips in 36 pts Good Results CD No Tx • Stage 1 70% 20% • Stage 2 71% 0% • Stage 3 73% 10%
  • 30. Kaplan-Meier survival curves Core decompression of 128 femoral heads in 90 pts with Ficat 1,2 or 3 disease Stage 5 yr 10 yr 15 yr No Further Surgery Needed 1 100% 96% 90% 88% 2 85% 74% 66% 72% 3 58% 35% 23% 26% Despite good clinical results 56% of hips progressed at least 1 Ficat stage Core decompression with electrical stimulation results ~ the same as core decompression alone Conclusion: Core decompression delays the need for THR
  • 31. Kaplan-Meier survival curves Free vascularized fibula grafting Stage requiring THR at 5 years 2 11% 3 23% 4 29% Results are for better than core decompression alone.
  • 32. Proximal Femoral Osteotomy Intact weight bearing area after transposition %Success  60%, 100%  36%, - 59% 93%  21% - 35% 65% < 20% 29% More normal bone at wt. bearing area Better the result of Osteotomy
  • 33. Irrespective of Classifications Basic questions for treatment? • How early to interfere? • How much to interfere? • Can we wait? • When to start , if at all, Bisphosphonate? Head collapsed – Head not collapsed Preservation or sacrifice
  • 34. The basic question ? • Head preservation – without collapse • No Tx • Drilling alone • Core decompression • CD + Cancellous / free fibula graft • CD + Muscle pedicle graft • CD + vascularized fibula graft
  • 35. The basic question ? • Head preservation – with collapse • Varus osteotomy • Valgus osteotomy • Sugiako anterior rotation osteotomy
  • 36. The basic question ? • Head sacrifice – • Surface replacement (Birmingham's) • Non – cemented THR • Cemented THR • Cemented / Non cemented Bipolar • Non cemented AMP • Girdle Stone – Excision arthroplasty
  • 37. Pre-Collapse Hips • Check extent of lesion If less than 30% -core decompression • greater than 30% - can consider core/electrical stimulation but needs evaluation for post-collapse methods depending on age, compliance, ongoing disease, etc. Guide-lines for management
  • 38. Pre-Collapse Hips Location of lesion Type A (medial) - observation with periodic followup i. Type B,C - Core decompression Other considerations: i. Diagnosis: SLE do worse ii. Continued Steroid / Alcohol : Do Worse iii. Age and compliance Guide-lines for management
  • 39. Strut Grafting Fibula Grafting • Decompression of Femoral Head • Removal of Necrotic Bone • Grafting of defect with cancellous graft • Viable cortical Bone strut to support subchondral bone. • Age 20 – 50, stage 2 – 4
  • 40. Surgery - Core decompression • Improves circulation by decreasing intramedullary pressure and preventing further ischemia and progressive joint destruction. • The best results vary from 34-95%, which is significantly better than results of conservative treatment. • The best results are obtained when treating patients with early AVN (precollapse). • Core decompression is also effective for pain control.
  • 41. Surgery - Core decompression + BG • Bone graft options include • structural cortical strut • Cancellous bone graft • Muscle-pedicle vascularized bone graft • Free vascularized fibular graft.
  • 42. Surgery - Core decompression + BG • Bone grafting is combined with the following: • Core decompression, which may interrupt the cycle of ischemia • Excision of sequestrum, which may inhibit revascularization of the femoral head. • Period of limited weight bearing. • The best results have been reported with free vascularised bone grafts. Success rates of 70% and 91% have been reported in 2 small series.
  • 43. Advantages • Advantages of free vascularized grafts compared to total hip arthroplasty include the following: • Healed femoral head may allow more activity. • No foreign body–associated complications occur. • If performed during early AVN, lifelong survival of the femoral head is possible. • The patient has the option of total hip arthroplasty in the future.
  • 44. Disadvantages • Disadvantages of free vascularized grafts include the following: • Longer period of recovery • Less complete pain relief. • Variable success rate • Lack of effectiveness in advanced disease
  • 45. 35 yr. F, post delivery 1992
  • 46. FU - post delivery pelvis July 2000
  • 47. 35 years F, post delivery AVN - 1988
  • 48. Same pt. post delivery AVN July 2000
  • 49. 55, Male alcohol - AVN
  • 50. Same pt. Fibula strut graft
  • 51. FU of the same Pt.
  • 52. AVN – Post Hip dislocation 2001
  • 53. Post Dislocation FU- 2006
  • 54. 2006
  • 55. Girdhar Gupta 2004Post cortisone 25 M - 2004
  • 56. Post cortisone 25 M
  • 57. Post cortisone 25 M - 2005
  • 58. Post cortisone 25 M -2006
  • 59. Post cortisone 30 M - 2003
  • 60. Post cortisone 30 M
  • 61. Post cortisone 30 M 2009
  • 62. Post cortisone 30 M 2009
  • 63. Post cortisone 35 M 2001
  • 64. Post cortisone 30 M – Fibula strut graft
  • 65. 2008 2003 Post cortisone 30 M - 2008
  • 66. 2008
  • 67. R. V. - 2001
  • 68. MRI-R. 27 F, 2001
  • 69. R.V. After 6 months
  • 70. R.V. After one year
  • 71. S.L. 40 M – post Cortisone
  • 72. S.L. 40 M – post Cortisone Bilateral grafting
  • 73. Ashok 2001
  • 74. Pre OP Post OP
  • 75. D.C. 3 yrs PO - 2001
  • 76. 2008 2008 D.C. 3 yrs PO - 2008
  • 77. 2008
  • 78. 2008
  • 79. G.24 M 2000
  • 80. 2008
  • 81. 2011
  • 82. 2011
  • 83. P.G. 30 M, cortisone induced - AVN Cancellous Bone grafting
  • 84. 2003 – P.G.
  • 85. 2007 – P. G.
  • 86. 2007
  • 87. Technique of Cancellous Bone grafting - Localization in C-arm - Guide wire in to lesion - Cannulated drilling - Curettage - Interlocking sleeve - Cancellous iliac graft - Packing with impactor/screw driver
  • 88. Vinod Nagar
  • 89. After 3 months
  • 90. M. 50 M CRF transplant left hip 1997 core decompression 3 years post op Oct. 2000
  • 91. Vascularised Free Fibula Graft “Healing Construct” • Decompression of Femoral Head • Removal of Necrotic Bone • Grafting of defect with cancellous graft • Viable cortical Bone strut to support subchondral bone. • Age 20 – 50, stage 2 – 4
  • 92. Summaries of cases with head preservation by free fibula grafting
  • 93. Post-Collapse Hips 1.Check extent of lesion i. less than 200 degrees Kerboul combined necrotic angles or less than 30% head involvement - consider osteotomy: ii. 20 degrees laterally preserved cartilage-varus osteotomy iii. not above- valgus osteotomy iv.greater than 200 degrees; consider bone grafting. Guide-lines for management
  • 94. Osteotomy • Several osteotomy procedures have been tried with variable success. • Intertrochanteric osteotomies have been performed in patients with posttraumatic AVN.
  • 95. Osteotomies • Transtrochanteric rotational osteotomy involves rotation of the femoral head and neck on the longitudinal axis. The necrotic anterosuperior part of the femoral head becomes posterior, and the weight- bearing force is transmitted to what was previously the posterior articular surface, which is not involved in the ischemic process. • In 1992, Sugano and colleagues reported excellent results in 56% of patients who underwent this procedure.[13] Transtrochanteric rotational osteotomy is technically demanding.
  • 96. K. K. 35 M AVN 1983 Osteotomy
  • 97. 19891983 K. K. 35 M AVN
  • 98. K. K. Aug. 2000
  • 99. R. J. 30 f post delivery left hip 1985
  • 100. R.J. post delivery left hip 1989
  • 101. M.- a 22 male took cortisone for weight gain and developed bilateral AVN. A varus osteotomy was done in 1997 on one side and core decompression on other side 2005 – came for removal of implants 1997 2000 2005 Osteotomy
  • 102. 2009
  • 103. 2009
  • 104. 2009
  • 105. A. 22 f CRF transplanted 2000
  • 106. After 2 years
  • 107. Replacement - options • Hemiarthroplasty • Bipolar arthroplasty • Surface replacement arthroplasty. • Newer material for THR ceramic on ceramic • Non cemented / cemented THR
  • 108. Post collapse Late-Collapse - symptomatic treatment till resurfacing or THR necessary Guide-lines for management
  • 109. K. - 1992
  • 110. K. 35 f 1999 after removal plate
  • 111. Bipolar Replacement on right side
  • 112. AMP Replacement on left side 2002
  • 113. 2011
  • 114. 2011
  • 115. S, 35 F 2008 2009
  • 116. 2009 2011
  • 117. 2011 2011
  • 118. Total hip arthroplasty • Most patients with advanced disease (stage III and above) require total hip arthroplasty. • Total hip arthroplasty provides excellent pain relief for many years, although most young patients require repeat surgery.
  • 119. Total hip arthroplasty • With high failure rates (10-50% after 5 y), patients with AVN will probably need a second total hip arthroplasty during their lifetime.
  • 120. M. post alcohol AVN Bil THR 1991
  • 121. M. Bil. THR 9 year post-op. Nov 2000
  • 122. B. 19 yrs, F, post cortisone
  • 123. Non Cemented THR
  • 124. AVN – Post # Neck Femur 1988 2002 20061990
  • 125. R. B. – 45 F
  • 126. R. B. – 45 F
  • 127. Bhalchand AMP – Rt - 1988 THR – Lt - 1991
  • 128. 2005 Poly wear
  • 129. 2007
  • 130. THR removed due to persistent pain cause? AMP still working
  • 131. Study/year/ design Technique Hips Precollapse Failures Postcollapse Failures Maniwa et al. CD w/wo NVG 26 26 8 (30.8%) Steinberg et al. D/NVG/EStim 312 198 63 (31.8%) 105 48 45.7%) Gangji et al.) CD 8 8 2 (25%) CD/BMG 10 10 0 (0%) Hernigou et al CD/BMG 189 136 23 (16.9%) 7 7 (100%) Yang et al. CD/BLAC 56 48 5 (10.4%) 8 4 (50%) Tsao et al. CD/TR 113 94 18 (19.1%) 19 4 (21%) Shuler et al. CD/TR 22 22 3 (13.6%) Kim et al. VFG 23 10 1 (10%) 13 7 (53.8%) NVFG 3 10 5 (50%) 13 11 (84.6%)
  • 132. Psychosocial - AVN • Drugs for gain in weight. • Steroid like drugs • Herbal/ Aurvedic/ Chinese/ • Drugs for improved performance in sex. These drugs may be mixed with steroids which may cause AVN
  • 133. Weight gain medicines
  • 134. Performance improving drugs
  • 135. Carry Home Message – Anterior Hip pain + Cortisone • Anterior hip pain in a young adult male should be consider as AVN till proved otherwise. • History of Cortisone may be in very small dosage or for a very short time can cause AVN in sensitive patient who have deficiency of Cytochrome P450 3A (steroid-metabolizing hepatic enzyme). • suppression of CYP3A activity significantly increased vulnerability to steroid-induced osteonecrosis, while increased CYP3A activity reduced this vulnerability.
  • 136. Carry Home Message – Management Phylosophy • Early diagnosis • Early decompression • Calcellous bone graft • Bisphosphonate • Osteotomy • Replacement arthroplasty
  • 137. • Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 32 years. • It is intended for use only by the students of orthopaedics. • Many GIF files are taken from Internet. • Views and opinions expressed in this presentation are personal. • Depending upon the x-rays and clinical presentations viewers can make their own opinion. • For any confusion please contact the sole author for clarification. • Every body is allowed to copy or download and use the material best suited to him. • I am not responsible for any controversies arise out of this presentation. • For any correction or suggestion or copy right violation please contact naneria@yahoo.com DISCLAIMER
  • 138. Thank You The End Of AVN Story