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CASE HISTORY
41-year-old male presented with
PAIN
 Site: right sided low back, hip and knee pain
 Onset: from past six months. Fell ...
PAST HISTORY
 Flu vaccine 14 months prior to injury.
 He subsequently developed an allergic reaction and was
diagnosed w...
PHYSICAL EXAMINATION
 Severe pain and restricted movement across hip joint.
 Right hip region extreme tenderness
 Muscl...
ON X-RAY
Irregularity to the right
femoral head
Sclerosis
Subchondral lucency
Mild collapse
DIAGNOSIS
AVASCULAR NECROSIS
(AVN)
DEFINITION
Cellular death of bone components due to
interruption of the blood supply;
the bone structures then collapse,...
ETIOLOGY
 TOXIC (alter lipid metabolism)
 STEROID NOT LESS THAN TWO YEAR INTAKE
 ALCOHOL
 DRUD IMMUNOSUPPRESSIVE ANTI-...
PATHOPHSIOLOGY
PATHOPHYSIOLOGY
 Interruption of the blood supply to the bone
 Effected bone have single terminal blood supply such as f...
EPIDEMIOLOGY
 RACE:-
 Associated with sickle cell anemia, hemoglobin S and SC
 SEX:-
 More common in men. Male to fema...
FICAT classification (5 stages) most commonly used
MITCHELL classification (4 types)
Steinburg classification (7 stages...
 No changes are visible.
 Plain film:
 normal
 MRI:
 normal
 Clinical symptoms:
 nil
STAGE I
STAGE II
 plain film:
 Normal or minor osteopenia
 Avascular areas are of increased
density (ostesclerosis)
 MRI:
 Ed...
STAGE III
 Plain film:
Mixed osteopenia
Sclerosis
 Subchondral cysts
without any subchondral
lucency
 MRI:
Geographi...
STAGE IV
 Plain film:
 Crescent sign and cortical collapse
 MRI:
 Same as plain film
 Clinical symptoms:
 Pain and s...
STAGE V
 plain film:
 End stage with evidence of secondary
degenerative change (joint space narrowing)
 Collapsed
 MRI...
MRI staging of AVN
CLASS TI WEIGHT IMAGE T2 WEIGHT IMAGE Grading lesion
acuity
A BRIGHT INTERMEDIATE FAT SIGNAL
B BRIGHT B...
MODALITY OF CHOICE
 X-RAY
 CT
 MRI
 RADIONUCLIDE BONE SCAN
X-RAY
 Mild-to-moderate AVN
Sclerosis (arrows)
Changes in bone density (asterisk).
X- RAY
Advanced disease
Bone deformities
Flattening
Subchondral radiolucent
lines (crescent sign)
Collapse of the fem...
Computed Tomography
 To assess
 the extent of the disease
 Calcification
 Less sensitive then MRI
Computed Tomography
Sclerosis in the central part of
femoral head asterisk sign
(arrow head)
Low-density region (arrow)
Radionuclide Bone Scan
 In early AVN
 Less sensitive than MRI
 Findings are nonspecific
 Unilateral disease,
 Healthy...
Early AVN
 Sensitivity of radionuclide bone scan is better than plain films .
 Central area of decreased uptake is surro...
Magnetic Resonance Imaging
 Most sensitive (~95%) modality
 Demonstrates changes well before plain film changes are visi...
Magnetic Resonance Imaging
 Decreased signal intensity in the subchondral region on both T1- and T2-
weighted images, sug...
Magnetic Resonance Imaging
 The next stage is characterized by a reparative process (reactive zone) and shows
 Low signa...
Advanced AVN
 Deformity of the articular surface
 Calcification
TREATMENT
 Medical management:
 Conservative measures
 Limit weight bearing
 Pain medications.
 Immobilization
 Bisp...
COMPLICATIONS:
 Total destruction of the joint may occur.
 Nonunion of fracture
 Secondary muscle wasting.
PROGNOSIS
 Depends on the disease stage at the time of diagnosis
 More than 50% of patients with AVN require surgical tr...
Avascular Necrosis
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Avascular Necrosis

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Radiology cases on avascular necrosis

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Avascular Necrosis

  1. 1. CASE HISTORY
  2. 2. 41-year-old male presented with PAIN  Site: right sided low back, hip and knee pain  Onset: from past six months. Fell from two meter high roof land on his feet  Intensity: worsening pain with time  Pattern: antalgic limp and walked with the help of a cane.  Radiation: into his right groin and anteromedial thigh region.  Aggravating factors: walking and stair climbing.  Relieving factors: sitting and resting.  NO ASSOCIATED SYMPTOMS
  3. 3. PAST HISTORY  Flu vaccine 14 months prior to injury.  He subsequently developed an allergic reaction and was diagnosed with leukocytoclastic vasculitis skin eruptions.  Treated with four months of oral corticosteroid therapy with doses up to 50 mg per day. The skin lesions resolved with treatment.  However he developed corticosteroid-induced glucose intolerance subsequent to treatment.  Past history also revealed a nasal fracture six years ago which required two surgical interventions.  No other significant point.
  4. 4. PHYSICAL EXAMINATION  Severe pain and restricted movement across hip joint.  Right hip region extreme tenderness  Muscle atrophy noted in the right region  Posterior joint provocation tests were painful for L4, L5.  SI testing was painful for the right sacroiliac joint.
  5. 5. ON X-RAY Irregularity to the right femoral head Sclerosis Subchondral lucency Mild collapse
  6. 6. DIAGNOSIS AVASCULAR NECROSIS (AVN)
  7. 7. DEFINITION Cellular death of bone components due to interruption of the blood supply; the bone structures then collapse, resulting in bone destruction pain loss of joint function.
  8. 8. ETIOLOGY  TOXIC (alter lipid metabolism)  STEROID NOT LESS THAN TWO YEAR INTAKE  ALCOHOL  DRUD IMMUNOSUPPRESSIVE ANTI-INFLAMMMATORY  TRAUMATIC (vascular occlusion)  IDIOPATHIC  FRACTURES  RADIOTHERAPY  INFLAMMMATORY  SLE  INFECTION  RHEUMATOID ARTHRITIS  HEMOPOIETIC DISORDERS (intravascular coagulation)  SICKLE CELL ANEMIA  HAEMOPHILIA  MISCELLANEOUS
  9. 9. PATHOPHSIOLOGY
  10. 10. PATHOPHYSIOLOGY  Interruption of the blood supply to the bone  Effected bone have single terminal blood supply such as femoral head and condyles, epiphysis of long bone carpals, talus, humerus,  These bone have limited collateral blood supply  Interruption of the vascular supply result in necrosis of  bone marrow (2-5 days)  Hemopoietic tissues (6-12 hours)  Osteoblast, osteoclast, osteocystes (12-48 hours)
  11. 11. EPIDEMIOLOGY  RACE:-  Associated with sickle cell anemia, hemoglobin S and SC  SEX:-  More common in men. Male to female ratio 8:1  AGE:-  Middle age fourth or fifth decade of life
  12. 12. FICAT classification (5 stages) most commonly used MITCHELL classification (4 types) Steinburg classification (7 stages) Radiologically AVN Staging System:
  13. 13.  No changes are visible.  Plain film:  normal  MRI:  normal  Clinical symptoms:  nil STAGE I
  14. 14. STAGE II  plain film:  Normal or minor osteopenia  Avascular areas are of increased density (ostesclerosis)  MRI:  Edema  bone scan:  Increased uptake  clinical symptoms:  Pain typically in the groin
  15. 15. STAGE III  Plain film: Mixed osteopenia Sclerosis  Subchondral cysts without any subchondral lucency  MRI: Geographic defect  Bone scan: Increased uptake  Clinical symptoms:  Pain and stiffness
  16. 16. STAGE IV  Plain film:  Crescent sign and cortical collapse  MRI:  Same as plain film  Clinical symptoms:  Pain and stiffness+/- radiation to knee and limp  Sub classification depends on the extent of crescent, as follows:  Stage a: Crescent is less than 15% of the articular surface.  Stage b: Crescent is 15-30% of the articular surface.  Stage c: Crescent is more than 30% of the articular surface.
  17. 17. STAGE V  plain film:  End stage with evidence of secondary degenerative change (joint space narrowing)  Collapsed  MRI:  Same as plain film  clinical symptoms:  Pain and limp  Sub classification on the extent of collapsed surfaces:  Stage a: Less than 15% of surface is collapsed.  Stage b: Approximately 15-30% of surface is collapsed.  Stage c: More than 30% of surface is collapsed.
  18. 18. MRI staging of AVN CLASS TI WEIGHT IMAGE T2 WEIGHT IMAGE Grading lesion acuity A BRIGHT INTERMEDIATE FAT SIGNAL B BRIGHT BRIGHT BLOOD SIGNAL C INTERMEDIATE BRIGHT FLUID/ EDEMA SIGNAL D DARK DARK FIBROSIS SIGNAL
  19. 19. MODALITY OF CHOICE  X-RAY  CT  MRI  RADIONUCLIDE BONE SCAN
  20. 20. X-RAY  Mild-to-moderate AVN Sclerosis (arrows) Changes in bone density (asterisk).
  21. 21. X- RAY Advanced disease Bone deformities Flattening Subchondral radiolucent lines (crescent sign) Collapse of the femoral head
  22. 22. Computed Tomography  To assess  the extent of the disease  Calcification  Less sensitive then MRI
  23. 23. Computed Tomography Sclerosis in the central part of femoral head asterisk sign (arrow head) Low-density region (arrow)
  24. 24. Radionuclide Bone Scan  In early AVN  Less sensitive than MRI  Findings are nonspecific  Unilateral disease,  Healthy side can be used for comparison  Bilateral disease:  difficult to interpret
  25. 25. Early AVN  Sensitivity of radionuclide bone scan is better than plain films .  Central area of decreased uptake is surrounded by an area of increased uptake.  Doughnut sign (arrow):  The reactive zone surrounding the necrotic area.
  26. 26. Magnetic Resonance Imaging  Most sensitive (~95%) modality  Demonstrates changes well before plain film changes are visible.  The progression is:  Diffuse oedema  Focal serpentine low signal line with fatty center (most common appearance)  Double line sign on T2WI is diagnostic  Osteochondral fragmentation: rim sign  Secondary degenerative change
  27. 27. Magnetic Resonance Imaging  Decreased signal intensity in the subchondral region on both T1- and T2- weighted images, suggesting edema (water signal) in early disease.
  28. 28. Magnetic Resonance Imaging  The next stage is characterized by a reparative process (reactive zone) and shows  Low signal intensity on T1-weighted scans ( band like area)  High signal intensity on T2-weighted scans. (double line sign)
  29. 29. Advanced AVN  Deformity of the articular surface  Calcification
  30. 30. TREATMENT  Medical management:  Conservative measures  Limit weight bearing  Pain medications.  Immobilization  Bisphosphonates  Delay collapse of the femoral head  Delay the need for surgical intervention.  Statin therapy  Prevents corticosteroid-induced  Surgical Management:  In early stages:  Core decompression with or without bone graft  In late stages:  Total hip arthroplasty is the most appropriate treatment
  31. 31. COMPLICATIONS:  Total destruction of the joint may occur.  Nonunion of fracture  Secondary muscle wasting.
  32. 32. PROGNOSIS  Depends on the disease stage at the time of diagnosis  More than 50% of patients with AVN require surgical treatment within 3 years of diagnosis.  Half of patients with subchondral collapse of the femoral head develop AVN in the contralateral hip.  Poor prognostic factors:  Age older than 50 years  Advanced disease (stage 3 or worse) at the time of diagnosis  Non-modifiable risk factors such as cumulative dose of corticosteroids (corticosteroid- induced AVN)

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