AVASCULAR NECROSIS   FEMORAL HEAD         By :   Dr. Rajat Malot Assistant ProfessorSMS Medical college        Jaipur
How to Approach a patient with          Hip Pain• Detailed History :   Trauma ,Drug intake,Any other joint  involvement,Co...
Anterior Hip pain or Lateral pain or              Posterior hip painGroin pain           Trochanteric painRule out: hip   ...
CLINICAL PRESENTATION No distinguishing Clinical Features/ High index of  suspicion Asymptomatic Pain gradual & insidiou...
Characteristics Of Pain Focal over the groin / hip or it may radiate to the buttocks,  anteromedial thigh or knee Induce...
Range Of Motion ROM may be diminished, especially after collapse of the  femoral head ROM may be limited, especially in ...
BLOOD SUPPLY OF FEMORAL HEAD The principal sources are the Lateral Epiphyseal Vessels  (LEVs). LEVs             Posterio...
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   transition...
AVN HISTORY Konig (1888) => first described the condition coined the  term Osteochondritis Dissecans Haenish (1925) => f...
AVASCULAR NECROSIS Misnomer; Basically it is Osteonecrosis (dead bone) Also c/a Osteochondritis Dissecans / Chandler’s D...
AVASCULAR NECROSIS M/c affects => Femoral Head M/c site => Anterolateral aspect (Being principal Wt.  bearing portion) ...
Does Elderly Persons are at                              increased risk for AVN?????                                      ...
ETIOLOGYIntravascular              ExtravascularExtraosseous               Intraosseousvascular factor              fact...
Extraosseous Vascular FactorsArterial Factors  Most important  Femoral Head blood supply is an End-Organ System   with p...
Intraosseous Vascular FactorsArterial Factors     Circulating microemboli that block the      microcirculation of the fem...
Intraosseous Vascular FactorsVenous Factors  Enlargement of intramedullary fat cells or fat-loading   osteocytes causes t...
Extravascular FactorsIntraosseous Factors  Ficat et al demonstrated increased bone marrow   pressure in the femoral necks...
Extravascular FactorsCapsular Factors          Trauma, Infection & Arthritis           Effusions within the Hip joint     ...
SEQUELAE OF AVNMinimal AVN                 More Severe AVN Avascular area is small    Once AVN develops, repair  & is no...
SEQUELAE OF AVN                 MECHANICAL FAILURE         Non-healing Micro# in Subchondral regionCollapse of the     Vic...
CAUSES Trauma                         Gout and hyperuricemia Alcohol consumption            Hypercholesterolemia Cort...
Mechanism of Development of AVN d/t Trauma
CAUSESSteroid (35-40%) 6 mechanisms•   Fat Emboli from the liver => Occlusion of Small Vessels•   Steroid     Intramedull...
Investigations       MRI                SPECT                 CT Scan             Plain X-Ray   Most Sensitive      Refl...
Radiology- sequential      Changes• Crescent Sign• Osteoporosis• Sclerosis• Cystic changes• Loss of spherical weight  bear...
MRI Findings Classic Findings:- look for focal lesion in the  anterosuperior portion of femoral head that is well  demarc...
MRI T1image     ∀ ↓ signal from       ischemic marrow     • Single band like       area of low signal       intensity.    ...
Double Line sign – T2       image          • A second high            signal intensity            seen within the         ...
Early
FEMORAL HEADCHANGES
CORONAL T2-WEIGHTED MRI
Prominent & Thickened                                 but Normal Trabeculae             ASTERISK SIGNAxial CT: Patient wit...
TRANSIENT OSTEOPOROSIS OF THE HIP               (TOH)    D/D:- No findings of bone infarction or repair, which are the ha...
CLASSIFICATION & STAGING   • In the 1960s, Arlet & Ficat in France   described a 3-part staging system & in the   1970s a ...
Paul FICAT                                1917-1986 FICAT’s scientific works spanned a wide range of topics from  ligamen...
Ficat & Arlet Classification              t Stages of Bone Necrosis   Stage            Clinical Features   Radiographs0 Pr...
A major disadvantage was that it didn’t include any  measurement of lesion size or articular surface                  invo...
Radiographic Staging                  (Marcus et al 1973) Stage 1 : Asymptomatic, mottled increased density of           ...
Steinberg et al (1995) Modified  Ficat & Arlet ClassificationStage 0 – 3 :- Same as Ficat ArletStage 4 :- Flattening of fe...
 1974, Kerboul et al noted that the results of osteotomies  performed for osteonecrosis depended on both the location &  ...
Kerboul:- combined necrotic angle –          AP          LAT
University Of Pennsylvania  Classification of Osteonecrosis 0 Normal or nondiagnostic x-ray, bone scan, and MRI I Normal...
University Of Pennsylvania  Classification of Osteonecrosis IV Flattening of femoral head  A. Mild (15% of surface and 2 ...
 1991, The Committee on Nomenclature & Staging of the  Association Research Circulation Osseous (ARCO) endorsed  the stag...
Mitchell’s MRI StagingClass     T1             T2             DefinitionA         Bright         Intermediate   Fat signal...
Criteria For Diagnosis           (Current Concept JBJS Mont & Hungerford)Specific Criteria                    Non specific...
AIM OF TREATMENT Preserve rather than Replacing Femoral Head &  Cartilage Early Intervention has favorable impact on the...
Medical Management Indications:- Small, Asymptomatic lesions Lesion is so advanced that prophylactic measures  would be ...
PROTECTED WEIGHT BEARING Protect the involved area from excessive stress by using some form of limited  weight bearing. C...
Glueck & colleagues => Incidence ofosteonecrosis in association with certainCoagulopathies & Hyperlipidmias
Stanozolol anabolic androgenic steroid potenialmeans of treating AVN associated withCoagulopathies & Hyperlipidemias
Motomura et al => Incidence of Steroid-inducedosteonecrosis in rabbits using a combination ofWarfarin & Probucol (Lipid Lo...
ENAXOPARIN adminstered for 12 weeks wasfound to prevent radiographic Progression ofStage 1 and Stage 2 idiopathic osteonec...
Gauthier => 95%-100% of transplant patientswho were treated with Calcium ChannelBlockers experienced complete relief of Bo...
I.V. ILIOPROST, a Vasoactive Prostacyclinanalogue showed significant improvements inpatients with Bone Marrow Edema Syndro...
Oral Nifedipine => Relief of bone pain reportedin 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  improv...
Bisphosphonates => reportedly causingOsteonecrosis of the Jaw , so should be usedcautiously
Puerarin :- An extract of the kudzu vine , is purported to  Cholesterol, Platelet Aggregation & cause Vasodilation. In a ...
Electric, Electromagnetic & Acoustic T/t     Pulsed Electromagnetic Field stimulation, is      reported to be useful for ...
Radiographic progression in Ficat stage II . Hips treated with core decompression  (CD) plus pulsed electromagnet fields (...
Extracorporeal Shockwave Therapy  There are only 2 papers in Pubmed  The only study is by Wang et al who compared the   ...
Hyperbaric oxygen (HBO) HBO improves oxygenation, reduces oedema & induces  angioneogenesis, a reduction in intra osseous...
Bone Marrow Injections Supplemented with Core Decompression  Principle:-  The small no. of progenitor cells in the proxim...
Bone Marrow InjectionsTechnique Usual site => Anterior Iliac Crest  A beveled metal trocar of 6 to 8 cm  length & a bore ...
Bone Marrow Injections Current Indications:- The best indications are hips with osteonecrosis &  without collapse In som...
Bone Marrow Injections
Surgical proceduresJoint Preserving       Joint Replacing Core                        Total Hip Decompression           ...
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 pati...
Core DecompressionStandard Technique & its Variations:- Ficat & Arlet proposed creating an 8 to 10 mm dia core  track & t...
Core Decompression Postoperative Management The lateral cortical window produces a stress riser in the  proximal femur So...
Bone Grafting Procedures Bone grafting procedures are a group of joint preserving  techniques that involve the removal of...
Bone Grafting Procedures Techniques:- Grafting Through Lateral Core Track Grafting Through Femoral Neck Window Grafting...
Grafting Through Lateral Core Track
Grafting Through Lateral Core Track     Advantages:-    Simple technique    Minimal Invasiveness    Avoidance of surgic...
Grafting Through Femoral Neck Window   Watson-Jones or Smith-Peterson approach    is used   A window is created to expos...
Grafting Through Articular SurfaceWindow The 3rd method of accessing the necrotic segment of the femoral head is  known a...
Grafting Through Articular SurfaceWindow
Types of Bone Grafts Nonvascularized Grafts          Vascularized Grafts Nonvascularized cortical     2. Local pedicled g...
Muscle-Pedicle Bone Grafts
Muscle-Pedicle Bone Grafts Baksi et al (1991) => results in treating 68 hips  with a variety of muscle-pedicle bone graft...
The harvested fibula with marbleized muscle attached confirming anextraperiosteal dissection. The peroneal artery & two ac...
Proximal Femoral Osteotomies The main rationale proposed for the efficacy of  osteotomies is the biomechanical effect of ...
Proximal Femoral Osteotomies Categories:- Valgus or varus osteotomies usually  combined with flexion or extension Transt...
Proximal Femoral Osteotomies Indications:- For varus or valgus osteotomies depend  on the location & size of the lesion ...
VALGUS OSTEOTOMY WITH          FLEXION• when the necrotic segment is located in  the anterosuperior part of the femoral  h...
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...
ROTATIONAL OSTEOTOMY             before rotation                                                  After rotationTransposit...
ROTATIONAL OSTEOTOMY
Hip Resurfacing ProceduresFemoral & Acetabular Surface Replacement & Hemi- Surface Replacement for Osteonecrosis of the Hi...
Metal-on Polyethylene Resurfacing    Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971)    independently were the fir...
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 p...
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 woul...
Arthrodesis Mostly a salvage procedure in contemporary orthopedics In the patient with significant pain & disability & i...
Resection Arthroplasty T/t of last resort Complete resection of the head & neck of the femur Can achieve a good range o...
Acrylic Cement Injection Debriding the necrotic zone then elevating & supporting the  collapsed segment by the injection ...
POROUS TANTALUM ROD INSERTION A novel approach in T/t of stage I & II precollapse osteonecrosis This rod functions analo...
POROUS TANTALUM ROD INSERTION
Sir Astley Paston COOPER                            1768–1841“Young medical men find it so much easier to speculate then t...
Thank you
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)
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)
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)
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Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)

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  • because they occur within an area of dead bone
  • delicate, sclerotic, raylike branchings emanating in a radial fashion from the central dense band
  • 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.
  • 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.
  • The improvement observed in hips treated with CD plus demineralized bone matrix (DBM), although not statistically significant, may be clinically significant.
  • (citric acid, sodium citrate, and dextrose).
  • This is because symptomatic ON is characterized by an elevated intramedullary pressure & creating a hole in the cortex & cancellous bone of the proximal femur has been observed to immediately reduce that pressure (personal observation).
  • Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)

    1. 1. AVASCULAR NECROSIS FEMORAL HEAD By : Dr. Rajat Malot Assistant ProfessorSMS Medical college Jaipur
    2. 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. 3. Anterior Hip pain or Lateral pain or Posterior hip painGroin pain Trochanteric painRule out: hip Rule out: hip Rule out: sciaticfracture, septic joint, fracture, bone tumor, nerve irritationand avascular referred pain from ,sacroiliitis due tonecrosis lumbar disc spondyloarthropathy, herniation lumbardisc or facet diseaseOther causes:OA, Other causes:RA, trochantericiliopectineal bursitis bursitis,OA, radiating Other causes:muscle from strain lumbar disc or facet disease
    4. 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. 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. 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. 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. 8. lateral circumflex A. Medial circumflex A. BLOOD SUPPLY OF FEMORAL HEAD
    9. 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. 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. 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. 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. 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. 14. ETIOLOGYIntravascular ExtravascularExtraosseous  Intraosseousvascular factor factors I. Arterial factors  Capsular factorsIntraosseousvascular factors I. Arterial factors II. Venous factors
    15. 15. Extraosseous Vascular FactorsArterial 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. 16. Intraosseous Vascular FactorsArterial 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. 17. Intraosseous Vascular FactorsVenous 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. 18. Extravascular FactorsIntraosseous 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. 19. Extravascular FactorsCapsular Factors Trauma, Infection & Arthritis Effusions within the Hip joint Intracapsular Pressure Tamponade of the LEVs
    20. 20. SEQUELAE OF AVNMinimal 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. 21. SEQUELAE OF AVN MECHANICAL FAILURE Non-healing Micro# in Subchondral regionCollapse of the Vicious Cycle Diffuse Subchondral #Articular Cartilage X-Ray :- Crescent Progressive Wt. Bearing Degenerative joint disease (DJD) & Joint Dissolution
    22. 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. 23. Mechanism of Development of AVN d/t Trauma
    24. 24. CAUSESSteroid (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 Activity10.A direct toxic effect occursSteroid Induced Blood Flow on osteogenic cells11.Hematopoietic Marrow Fatty Marrow > 20 mg & 6 Wks => Risk
    25. 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 or12. Size of the lesion cancellous # & collapse13. Gross estimates of
    26. 26. Radiology- sequential Changes• Crescent Sign• Osteoporosis• Sclerosis• Cystic changes• Loss of spherical weight bearing dome• Partial collapse of head• Secondary Osteoarthritis
    27. 27. 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
    28. 28. MRI T1image ∀ ↓ signal from ischemic marrow • Single band like area of low signal intensity. • 100% sensitivity • 98% specificity
    29. 29. Double Line sign – T2 image • A second high signal intensity seen within the line seen on T1 images. • Represent hyper vascular granulation tissue
    30. 30. Early
    31. 31. FEMORAL HEADCHANGES
    32. 32. CORONAL T2-WEIGHTED MRI
    33. 33. Prominent & Thickened but Normal Trabeculae ASTERISK SIGNAxial CT: Patient without AVN of the Femoral Head
    34. 34. 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
    35. 35. 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
    36. 36. 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 clinicianbut also the ability to see with the eyes of the physiologist, themicroscopist & even the electron microscopistHe was one of the few orthopedic clinicians with the ability to“see” problems at the cellular and subcellular level
    37. 37. Ficat & Arlet Classification t Stages of Bone Necrosis Stage Clinical Features Radiographs0 Preclinical 0 01 Preradiographic + 02 Precollapse + Diffuse Porosis, Sclerosis, Cysts3 Early Collapse ++ Crescent Sign Certain Sequestrum, Joint Space Normal4 Osteoarthritis +++ Flattened Contour Decreased Joint Space Collapse of Head
    38. 38. A major disadvantage was that it didn’t include any measurement of lesion size or articular surface involvement..
    39. 39. 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
    40. 40. Steinberg et al (1995) Modified Ficat & Arlet ClassificationStage 0 – 3 :- Same as Ficat ArletStage 4 :- Flattening of femoral headStage 5 :- Joint narrowing with or without acetabular involvementStage 6 :- Advanced degenerative changes These stages were further divided into Mild, Moderate & Severe
    41. 41.  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
    42. 42. Kerboul:- combined necrotic angle – AP LAT
    43. 43. 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%)
    44. 44. 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 changesFrom Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head: Results of core decompression and grafting with electrical stimulation
    45. 45.  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
    46. 46. Mitchell’s MRI StagingClass T1 T2 DefinitionA Bright Intermediate Fat signalB Bright Bright Blood signalC Intermediate Bright Fluid or edema signalD Dark Dark Fibrosis signal
    47. 47. 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
    48. 48. 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
    49. 49. 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
    50. 50. 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
    51. 51. Glueck & colleagues => Incidence ofosteonecrosis in association with certainCoagulopathies & Hyperlipidmias
    52. 52. Stanozolol anabolic androgenic steroid potenialmeans of treating AVN associated withCoagulopathies & Hyperlipidemias
    53. 53. Motomura et al => Incidence of Steroid-inducedosteonecrosis in rabbits using a combination ofWarfarin & Probucol (Lipid Lowering Agents)
    54. 54. ENAXOPARIN adminstered for 12 weeks wasfound to prevent radiographic Progression ofStage 1 and Stage 2 idiopathic osteonecrosisof the femoral head at 2 year follow up
    55. 55. Gauthier => 95%-100% of transplant patientswho were treated with Calcium ChannelBlockers experienced complete relief of BonePain Syndrome
    56. 56. I.V. ILIOPROST, a Vasoactive Prostacyclinanalogue showed significant improvements inpatients with Bone Marrow Edema Syndrome &Osteonecrosis
    57. 57. Oral Nifedipine => Relief of bone pain reportedin a small series of patients with Osteonecrosis
    58. 58. 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
    59. 59. Bisphosphonates => reportedly causingOsteonecrosis of the Jaw , so should be usedcautiously
    60. 60. 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
    61. 61. 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.
    62. 62. 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)
    63. 63. 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
    64. 64. 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
    65. 65. 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
    66. 66. Bone Marrow InjectionsTechnique 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
    67. 67. 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
    68. 68. Bone Marrow Injections
    69. 69. Surgical proceduresJoint Preserving Joint Replacing Core  Total Hip Decompression Arthroplasty Various  Hip Resurfacing Nonvascularized & Procedures Vascularized Bone Grafting Procedures Osteotomy Procedures
    70. 70. Core Decompression Core decompression was “discovered” by Paul Ficat & Jacques Arlet in the 1960s Incidental discovery
    71. 71. 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.
    72. 72. Core DecompressionStandard 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
    73. 73. 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
    74. 74. 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
    75. 75. Bone Grafting Procedures Techniques:- Grafting Through Lateral Core Track Grafting Through Femoral Neck Window Grafting Through Articular Surface Window
    76. 76. Grafting Through Lateral Core Track
    77. 77. 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 #
    78. 78. 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
    79. 79. 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
    80. 80. Grafting Through Articular SurfaceWindow
    81. 81. 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
    82. 82. Muscle-Pedicle Bone Grafts
    83. 83. 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
    84. 84. The harvested fibula with marbleized muscle attached confirming anextraperiosteal dissection. The peroneal artery & two accompanyingveins
    85. 85. 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
    86. 86. Proximal Femoral Osteotomies Categories:- Valgus or varus osteotomies usually combined with flexion or extension Transtrochanteric rotational osteotomies
    87. 87. 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
    88. 88. 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
    89. 89. VALGUS OSTEOTOMY WITH FLEXION AND BONE GRAFTING
    90. 90. VARUS OSTEOTOMY WITH FLEXION OR EXTENSION
    91. 91. ROTATIONAL OSTEOTOMIES• Sugioka first reported a transtrochanteric transposition osteotomy with anterior rotation of the head and neck of the femur
    92. 92. ROTATIONAL OSTEOTOMY before rotation After rotationTransposition of the necrotic focus to the ant. & inf. part of the femoral head awayfrom the weight-bearing area as a result of the ant. rotation of the head
    93. 93. ROTATIONAL OSTEOTOMY
    94. 94. Hip Resurfacing ProceduresFemoral & 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
    95. 95. 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
    96. 96. Metal-on-Metal Bearings Reduces the incidence of long-term failure from aseptic loosening & osteolysis
    97. 97. 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.
    98. 98. Bhumika – Non Cemented THR
    99. 99. Miscllaneous Procedures FEMORAL ENDOPROSTHESIS ARTHRODESIS RESECTION ARTHROPLASTY ACRYLIC CEMENT INJECTION
    100. 100. 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
    101. 101. 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
    102. 102. 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
    103. 103. 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
    104. 104. 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
    105. 105. POROUS TANTALUM ROD INSERTION
    106. 106. 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 toknowledge. Observations on diseased living, examinations of the dead & experiments upon living animals are the only sources of true knowledge.”
    107. 107. Thank you

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