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. Management protocol
• Early diagnosis
• Radiological evaluation
• Rule out other causes
• MRI
• Quantification
• Treatment algorithm
4. Early Diagnosis – suspicion ?
• High degree of suspicion in a patient C/o
anterior HIP pain, Especially with:-
H/o Cortisone – Skin, Eye, Liver, Asthma,
RA, Weight gain, PID –
H/o Alcohol abuse
Traumatic - # N/F, D/ of F, # Acetabulum
Hemoglobinopathy – Sickle / Myelo-infiltrating
9. The second step - MRI
• 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
etc.
10. 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
11. MRI T1 image
signal from ischemic
marrow
• Single band like area
of low signal intensity.
• 100% sensitivity
• 98% specificity
12. Double Line sign – T2 image
• A second high
signal intensity
seen within the line
seen on T1 images.
• Represent hyper
vascular
granulation tissue
15. 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
16. Staging / Grading --- too many
• Ficat
• Steinberg
• Enneking's
• Marcus and Enneking
• Japanese criteria
• Sugioka
Radiological
Quantification
Stages of Osteonecrosis
System
Location
Radiological
• University Of Pennsylvania System
• Association Research Classification Osseous
Committee (ARCO)-- Combination
17. Stage Clinical Features Radiographs
• 0 Preclinical 0 0
• 1 Preradiographic + 0
• 2 Precollapse
Sclerosis, Cysts
+ Diffuse Porosis,
• Transition: Flattening, Crescent Sign
• 3 Collapse ++ Broken Contour of Head
Certain Sequestrum,
Joint Space Normal
• 4 Osteoarthritis
Space
+++ Flattened Contour
Decreased Joint
Collapse of Head
Ficat Stages of Bone Necrosis
22. 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
23. The basic question ?
• Head preservation – with collapse
• Varus osteotomy
• Valgus osteotomy
• Sugiako anterior rotation
osteotomy
24. The basic question ?
• Head sacrifice –
• Surface replacement
(Birmingham's)
• Non – cemented THR
• Cemented THR
• Cemented Bipolar
• AMP
• Girdle Stone – Excision
arthroplasty
25. 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
26. 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
27. • 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
28. 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%
29. 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
3 100% 96% 90% 88%
4 85% 74% 66% 72%
5 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
30. Kaplan-Meier survival curves
Free vascularized fibula grafting
Sta years
ge requiring THR at 5
2 11%
3 23%
4 29%
Results are for better than core
decompression alone.
31. Proximal Femoral Osteotomy
Intact weight bearing
area after transposition %Success
60%,
36%, - 59%
21% - 35%
< 20%
100%
93%
65%
29%
More normal bone at wt. bearing area
Better the result of Osteotomy
32. •
•
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.
33. Pre-Collapse Hips
Location of lesion
Type A (medial) - observation with periodic
followup
iii. Type B,C - Core decompression
Other considerations:
v. Diagnosis: SLE do worse
vi. Continued Steroid: Do Worse
vii. Age and compliance
Guide-lines for management
34. 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
36. 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
37.
38. 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
71. Manoj- 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
90. THR
• Patient aged 50 & more
• Advance osteoarthritis and reduction of
joint space.
• Radiation necrosis
• Result less than Ideal. – necrotic bone
• Poor in Sickle cell disease.
• Cementless are superior over cemented
THR
