2. Avascular necrosis (also osteonecrosis,
bone infarction,aseptic necrosis,
ischemic bone necrosis,and AVN)
Disease where there is cellular death
of bone components due to
interruption of the blood supply
3.
4.
5. The LEV enters the femoral head within a 1-cm-
wide zone between the cartilage of the femoral
head and the cortical bone of the femoral
neck.
Supply the lateral and central thirds of the
femoral head
When patent, the artery of the ligamentum
teres (ALT) supplies the medial third of the
femoral head
10. AVN : areas of dead trabecular bone and
marrow extending to involve the subchondral
plate.
Anterolateral aspect of the femoral head, the
principal weightbearing region typically
involved, but any region of the femoral head
may be involved.
Involved segment usually never fully
revascularizes, and collapse of the femoral
head usually occurs
11. Elderly persons at decreased risk
Fat cells become smaller, space between fat
cells fills with a loose reticulum and mucoid fluid,
which are resistant AVN.
Condition is termed gelatinous marrow.
Even in the presence of increased
intramedullary pressure, interstitial fluid escapes
into the blood vessels, leaving the spaces free to
absorb additional fluid.
12.
13. Clinical picture nonspecific
Presenting symptom unilateral hip pain, which
may be followed by a limp and a decreased
range of motion (ROM).
Young adults between the ages of 30 and 40
most frequently affected
Bilateral in more than 50% of patients
14. Sequelae of avascular necrosis
Minimal AVN - If the vascular area is small and is
not adjacent to an articular surface, the patient
may be asymptomatic; healing may occur
spontaneously, or the disease may remain
undetected or be discovered incidentally
during workup for other conditions.
15. More severe AVN : repair begins at the interface
between viable bone and necrotic bone.
Dead bone reabsorbed only partially.
Reactive and reparative bone laid down on dead
trabeculae, resulting in a sclerotic margin of
thickened trabeculae within an advancing front of
hyperemia, inflammation, bone resorption, and
fibrosis.
Incomplete resorption of dead bone has a mixed
sclerotic and cystic appearance on radiographs.
Necrosis and repair are ongoing in various stages of
evolution within a single lesion.
16. Mechanical failure - In the subchondral region
microfractures do not heal
Progression of the microfractures results in a
diffuse subchondral fracture, seen
radiographically as the crescent sign
Following subchondral fracture and progressive
weightbearing, collapse of the articular
cartilage occurs
Continued fracture, necrosis, and further
weightbearing may progress to degenerative
joint disease (DJD) and joint dissolution
17. IMAGING MODALITIES
AP and lateral radiographs of both hips
Initially within normal limits because it takes a
period of weeks to months after the initiating
event for changes to appear on radiographs
The first changes to be noted are areas of
radiolucency and sclerosis within the femoral
head, usually in the anterior superior quadrant
18. If osteonecrosis suspected despite normal-
appearing plain radiographs, MRI of both hips
should be obtained because more than 50% of
cases are bilateral
19. MRI
Help guide interventional procedures such as
core decompression,
Demonstrate response of the femoral head to
treatment
Noninvasive means of evaluating articular
cartilage congruity
Sequential evaluation of asymptomatic lesions
undetectable on plain radiographs.
20. I DD
Plain film radiographs
Malignancy
Osteomyelitis
Transient osteoporosis of the hip
Bone sarcoma
Advanced Degenerative joint disease
Insufficiency fractures
Epiphyseal dysplasia
Bone metastases
21. Bone scintigrams
Infection
Plasma cell myeloma
Skeletal metastasis
Hemangioma
Radiation therapy
Arthritis
Sympathetic dystrophy
Bone marrow edema syndrome
Bone metastases
23. MRIs
Transient osteoporosis of the hip
Transient bone marrow syndrome
Bone bruise
Epiphyseal stress fracture
Infection
Infiltrative neoplasm
Insufficiency fracture
Bone metastases
24. Ficat and Arlet Radiographic Staging
System for AVN
Stage 0 (preclinical and preradiologic)
Avascular necrosis (AVN) can be suggested
only if it has already been diagnosed in the
contralateral hip.
25. Stage 1 (preradiologic)
Defined by normal findings on radiographs and
positive findings on MRI or bone scintigraphy.
Early resorptive stage,
Late in this stage, plain radiographs may show
minimal osteoporosis and/or blurring and poor
definition of the bony trabeculae
26.
27. Stage 2 (reparative)
Demineralization evident; first manifestation of
the reparative stage, represents resorption of
dead bone, and may be generalized or patchy
or appear in the form of small cysts within the
femoral head
28.
29. Anteroposterior view of the
pelvis in a patient with
bilateral avascular necrosis
of the femoral head. Mild
flattening to the superior
aspect of the right femoral
head (open arrow)
indicates stage 3 disease.
The left femoral head has a
normal contour, indicating
stage 2 disease.
30. Stage 3 (early collapse of the femoral
head )
Linear subcortical lucency, representing a fracture line,
present immediately beneath the articular cortex and
may extend into the articular cartilage at the
superolateral aspect of the femoral head.
Crescent sign ; best demonstrated on a frogleg view
Subarticular cortex remain attached to the cartilage
and is separated from the underlying femur by soft tissue,
termed the eggshell sign.
The femoral head initially preserves its round
appearance, but later, it demonstrates collapse,
indicated by joint-space widening.
31. Frogleg lateral view of the right hip in a patient with avascular necrosis shows the
crescent sign, indicating subchondral fracture.
32.
33. Stage 4 (progressive degenerative disease)
Further flattening of the femoral head with loss
of its smooth convex contour
Ultimately, the superior femoral fragment,
representing the articular surface and the
immediate subchondral bone become
separated from the underlying femoral head or
depressed and compacted into the femoral
head.
Fragments of bone and cartilage may separate
from the underlying femur, become loose
bodies.
34. Severe collapse and
destruction of the femoral
head leads to progressive
degenerative joint
disease (DJD) with joint-
space narrowing,
marginal osteophyte
formation, and
subchondral cyst
formation
35. Steinberg et al's Staging System for AVN
Steinberg et al proposed a 6-stage classification
system based on that of Ficat and Arlet and
included radiologic clinical classification
findings
36. Stage 0 - both preclinical and preradiologic,
identified when imaging is performed to evaluate
AVN in the contralateral hip or to exclude other
diseases. Abnormal MRI findings, normal
radiographic findings, and normal bone scan
findings
Stage 1 - normal radiographic findings or minimal
demineralization or blurred trabeculae,Pain in the
anterior groin or thigh ,Limited ROM in the hip
Stage 2 - Osteoporosis, groin pain, and mottled
sclerotic and/or cystic area
37. Stage 3 - crescent sign (subchondral fracture) ,
pain with subchondral fracture activity, and no
femoral head flattening
Stage 4 - marked collapse and fracture
involving the articular surface, Segmental
flattening, pain with femoral head activity, no
acetabular involvement, and normal joint space
Stage 5 - joint space narrowing, resting pain,
and acetabular degeneration (DJD)
39. Class A - Central osteonecrotic focus signal analogous to that of fat are
noted. Increased signal is demonstrated on T1WIs, and intermediate to
high signal is demonstrated on T2WIs
40. Class B - The presence of central osteonecrotic focus signal analogous to that of blood is observed. Increased
signal is demonstrated on both T1WIs and T2WIs
41. Class C - Central osteonecrotic focus signal analogous to that of fluid is present. Decreased signal is
demonstrated on T1WIs, and increased signal is demonstrated on T2WIs
42. Class D - The presence of central osteonecrotic
focus signal analogous to that of fibrous tissue is
noted. Decreased signal is demonstrated on
both T1WIs and T2WIs
45. To determine the most appropriate treatment,
consider the following aspects:
age of the patient, stage of the disease (early or
late),location and amount of bone
affected (small or large area),underlying cause
of AVN (with ongoing causes such as
corticosteroid or alcohol use, treatment may not
work unless use of the substance is stopped)
48. Restricted weight-bearing
Advised with the expectation of preventing femoral
head collapse during the healing
Only 5 studies with reference to weight bearing as
treatment modality
Factors related to resolution : early, asymptomatic
disease (ARCO stage I) and small lesion size (a
modified index of necrotic extent of < 25).
Hernigou et al, observed that clinical and
radiographic signs of the disease in asymptomatic
hips with a very small asymptomatic lesion progress
more slowly than do signs in hips with a large
symptomatic stage-II lesion
49. Agarwal et al studied 60 patients with AVN of the hip (100 hips ). All
patients were treated with alendronate 10 mg/day (or 70 mg/week)
along with 500-1000 mg of daily calcium and vitamin D supplements,
and were advised to avoid weight-bearing. NSAIDs and analgesics
were permitted as needed and were recorded.
CONCLUSION:
Alendronate reduces pain, improves function and retards AVN
progression. Early surgical intervention can be avoided in most
patients.
Rheumatology (Oxford) 2005
Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of
the hip. A prospective open-label study. Agarwala S, Jain D Joshi VR,
Sule A P. D. Hinduja Hospital, Mahim, Mumbai 400 016, India.
50. Operative intervention
1. Core decompression
2. Core decompression with bone grafting
Phemister type fibular grafting
Cancellous iliac bone grafting
Meyer’s Quardatus femoris muscle grafting
Sartorious muscle pedicle grafting
Tensor fascia lata pedicle grafting
Gluteus medius pedicle grafting
Vascularized muscle pedicle bone grafting
51. 3. Osteotomy
4. Surface arthroplasty
5. Total hip arthroplasty
52. Core decompression
2 methods of core decompression: large-
diameter trephines and small-diameter drills. The
most common method, the 8 to 10-mm
trephine, is completed under fluoroscopy with
the core track either being left open or filled in
with bone graft
53.
54. Complications e.g., articular cartilage damage
and subchondral fractures associated with the
large-diameter technique,
Kim et al. developed the multiple small-
diameter core decompression technique.
In their initial cohort of patients treated with this
technique, they reported a lower rate of
collapse (14.3%) as compared with the rate
reported with the traditional trephine method
Kim SY, Kim DH, Park IH, Park BC, Kim PT, Ihn JC. Multiple drilling compared with
standard core decompression for the treatment of osteonecrosis of the femoral
head [abstract]. J Bone Joint Surg Br. 2004;
57. Stulberg et al. compared core decompression
alone with conservative treatment in a
prospective, randomized study of 55hips. On
the basis of Harris hip scores, operative
treatment was successful in approximately 70%
of hips with Ficat Stage-I, II, or III osteonecrosis. In
contrast, nonoperative treatment was successful
for 20% of hips with Ficat Stage-I disease, 0% with
Stage-II,and 10% with Stage-III
Stulberg BN, Davis AW, Bayer TW, Levine M,Easley K. Osteonecrosis of the femoral head.A
prospective randomized treatment protocol Clin Orthop.
58. Smith et al. reviewed twelve articles, published
between 1979 and 1991, that included a total of
702 hips with an average duration of followup of
thirty-eight months. Using the University of
Pennsylvania staging system, they reported a
successful result in 78% of the Ficat Stage-I hips,
62% of the Stage-II hips, and 41% of the Stage- III
hips.
Smith SW, Fehring TK, Griffin WL, Beaver WB.Core decompression of the
osteonecrotic femoral head. J Bone Joint Surg Am
59. USE OF OSTEOINDUCTIVE SUBSTANCES ALONG
WITH CORE DECOMPRESSION
60. Mont et al used a modified trapdoor technique
and bone morphogenetic protein enriched bone
graft substitute through a window at the femoral
head-neck junction in 23 patients.
Successful clinical results (a Harris hip score of 80
points or greater and no additional procedures) in
18 of 21 hips (86%) at a minimum follow up of 36
months (mean, 48 months; range, 36–55 months)
Extensive dissection required and, technically more
difficult than a standard core decompression
Mont MA, Etienne G, Ragland PS. Outcome of nonvascularized bone grafting
for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2003
61. Lieberman et all retrospectively evaluated 15 patients (17 hips) with
AVN hip treated with core decompression combined with an
allogeneic, antigen-extracted, autolyzed fibula allograft and 50 mg
of partially purified human bone morphogenetic protein and
noncollagenous proteins
Clinical success in 14 of 15 hips (93%; 13 patients) with Stage IIA
disease.
3 of 17 hips had radiographic progress and converted to total hip
replacements.
Only 1of seven hips with 50% or less involvement of the femoral head
developed radiographic progression of the femoral head
No radiographic progression in the 3 hips with less than 1/3
involvement of the weight bearing surface of the femoral head.
Concluded further evaluation of the potential efficacy of bone
morphogenetic protein required in randomized trials.
Treatment of osteonecrosis of the femoral head with core decompression and human bone morphogenetic protein.
Lieberman JR
62. Mesenchymal stem cells (MSC) from adult bone
marrow are multipotent that can differentiate
into fibroblastic, osteogenic, myogenic,
adipogenic and reticular cells.These cells may
also provide a potential therapy for bone repair
Procedure of autologous stem cell
transplantation has been standardized with the
guidelines that these should be instilled in
concentration of 2X106 stem cells in non-
traumatic pre-collapse stage of avascular
necrosis femur head.
63.
64. Effectiveness of bone marrow mononuclear cells
related to the availability of stem cells endowed
with osteogenic properties
Injected marrow stromal cells secrete angiogenic
cytokines, resulting in increased angiogenesis
Bone marrow contains the bone morphogenetic
proteins such as BMP-2
Supplementation of bone marrow stromal cells
cultures with FGF-2 resulted in prolonged lifespan of
bone marrow stromal cells to more than 70
doublings and maintained their differentiation
potential accompanied by an increase of their
telomerase size
65. Yan et al treated 44 hips in 28 patients with AVN at early stage
by percutaneous multiple holes decompression followed by
autologous BMCs infusion. Autologous BMCs were
concentrated from bone marrow that was taken from the
posterior iliac crest of the patient. Patients were followed up at
least 2 years. The results were determined by the changes in
the Harris hip score and the progression in the radiograghic
stages.
They concluded ercutaneous multiple holes decompression
combined with autologous BMCs is a new way to treat
avascular necrosis of the femoral head.
Treatment of osteonecrosis of the femoral head by percutaneous
decompression and autologous bone marrow mononuclear cell infusion.
Yan ZQ, Chen YSLi , Yang Y Huo JZ Chen ZR Shi JHGe JB Source Department of
Orthopaedics, Zhongshan Hospital of Fudan University, Shanghai 200032,
China. healthbone@zshospital.net
66. Valerie et al studied the implantation of autologous bone-
marrow mononuclear cells in a necrotic lesion of the femoral
head along with core decompression.
After twenty-four months, significant reduction in pain (p =
0.021) and in joint symptoms within the bone-marrow-graft
group
Implantation of autologous bone-marrow mononuclear cells
appears to be a safe and effective treatment for early stages
of osteonecrosis of the femoral head.
Treatment of Osteonecrosis of the Femoral Head with Implantation of Autologous Bone-Marrow Cells
Valérie Gangji, MD1; Jean-Philippe Hauzeur, MD, PhD J Bone Joint Surg Am. 2005
67. Deltro et al, published their experience in 8 patients
where they assessed the efficacy and safety of
autologous bone-marrow mononuclear cells (BMMC)
implantation in necrotic lesions of the femoral head in
patients with sickle cell disease.
After 8 months, 7 of the eight patients reported
improvement from symptoms
Concluded autologous bone-marrow mononuclear cells
implantation is a safe and effective treatment for early
stages of femoral head osteonecrosis in patients with
sickle cell disease
Daltro GC, Fortuna VA, Salvino de Araújo SA, FerrazLessa PI, Sobrinho
UA, Borojevic R. Femoral head necrosis treatment with autologous
stem cells in sickle cell disease. Acta Orthop Bras. 2008;
68. Use of a tantalum implant reported in 2 studies
Tantalum is a light metal that has a high yield to stress. In
these studies, porous tantalum rods used to potentially
allow bone growth to occur while providing support.
While the short-term results in these studies compared
favorably to other core decompression techniques
longer follow-up is needed to more fully assess the
efficacy of this procedure.
Tsao AK, Roberson JR, Christie MJ, Dore DD, Heck DA, Robertson DD, Poggie RA.
Biomechanical and clinical evaluations of a porous tantalum implant for the
treatment of early-stage osteonecrosis. J Bone Joint Surg Am. 2005;87 Suppl 2: 22-
7.8722 2005
Veillette CJ, Mehdian H, Schemitsch EH, McKee MD. Survivorship analysis and
radiographic outcome following tantalum rod insertion for osteonecrosis of the
femoral head. J Bone Joint Surg Am. 2006;88 Suppl 3: 48-55.8848 2006
69. Bone-grafting procedures can be divided into
two general categories: non-vascularized and
vascularized
70. 3 approaches to introduce bone graft into the
femoral head
a core tract
window in the femoral neck (a ―lightbulb‖
procedure)
a ―trapdoor‖ made through the articular
cartilage in the femoral head
71. Cortical strut-grafting, a procedure popularized
by Phemister, Boettcher et al., and Bonfiglio et
al. not commonly used today
Technique involves the removal of an 8 to 10-
mm-diameter cylindrical core of bone from the
femoral head and neck. This core tract is then
filled with cortical strut grafts harvested from the
ilium,fibula, or tibia.
Postoperatively,protected weight-bearing for
three to six months
73. Lightbulb procedure
The term lightbulb procedure introduced by
Rosenwasser et al.
Cortical window lifted from the femoral head-neck
junction, cancellous bone graft from the iliac crest
used to fill the defect in the femoral head after
complete evacuationof the necrotic bone.
In their series, thirteen of fifteen hips were
asymptomatic at a mean of twelve years (range,
ten to fifteen years)
Rosenwasser MP, Garino JP, Kiernan HA, MichelsenCB. Long term
followup of thorough debridement and cancellous bone grafting
ofthe femoral head for avascular necrosis. ClinOrthop. 1994
82. Meyers (1978) reported that fresh autologous
iliac bone chips combined with a muscle-
pedicle bone graft gave good results in stages 1
and 2 necrosis, but was unsatisfactory in stages
3 and 4.
83. Technique for performing muscle-pedicle bone
grafting to the femoral head, modified after Meyers
et al
84. Baksi(1991) reported his results at 3 to 12 years
(mean, 7 years) follow-up in treating 61 patients
(68 hips) with a variety of muscle pedicle bone
grafts.
Tensor fascia lata anteriorly and the quadratus
femoris posteriorly preferred.
As many as 83% of the patients, obtained good
or excellent results at follow-up.
Baksi DP. Treatment of osteonecrosis of the femoral head by drilling and
muscle-pedicle bone grafting. J Bone Joint Surg Br. 1991;
92. The rationale for management of osteonecrosis of
the femoral head with a free vascularized fibular
graft based on five principles:
(1) decompression of the femoral head,
(2) removal of the necrotic bone,
(3) replacement with fresh autogenous cancellous
bone,
(4) support of the subchondral bone with a
viable strong bone strut,
(5) revascularization and osteogenesis of the
femoral head.
93. INDICATIONS:
Symptomatic patients younger than fifty years of
age with stage- II, III, or IV
Patients younger than 20 of age who have
stage-V disease and a good range of motion of
the hip
94. A 15-cm incision is made on the lateral aspect of the leg between the
lateral and posterior
compartments. The incision is begun 10 cm distal to the fibular head (PF)
and ends
10 cm proximal to the tip of the lateral malleolus (LM).
95. The yellow arrow is pointing to the anterior intermuscular septum. The black arrow is
pointing to the fibula, on which a small cuff of muscle and periosteum has been
preserved—
the so-called marbleizing technique
96. The interosseous membrane (IOM) is divided with a specially designed
right-angle Beaver
blade (white arrow). The close proximity of the deep peroneal nerve and
anterior tibial artery
(black arrow) can be seen in this photograph
97. The fibular osteotomy is performed once the pedicle
has been isolated distally and proximally
and protected with malleable retractors
98. The proximal stump of the peroneal artery is ligated with the hemostatic
clips (arrow) just
as it branches from the posterior tibial artery, ensuring at least a 4 to 5-cm
pedicle
99.
100.
101.
102.
103. Cancellous bone harvested from the greater trochanteric
area is inserted into the cavity formed
by removal of the necrotic bone. The fibular
graft is inserted into the core tract and stabilized
with a 0.62-mm Kirschner wire (K). The
peroneal veins and artery are anastomosed to
the ascending branches of the lateral femoral
circumflex artery (LFCA) and vein
104.
105.
106. Urbaniak reviewed the results in 1523 hips treated with a free
vascularizedfibular graft for osteonecrosis between 1979 and October
1, 2000
Best results obtained in the patients who had had no collapse of the
subchondral bone or articularcartilage preoperatively.
Of the hips that had not had preoperative subchondral or articular
collapse, 91% had a successful result after six months to twenty-two
years of follow-up.
If collapse had been present, the success rate was 85%, and if there
had also been joint-space narrowing, it was 65%
Urbaniak JR, Coogan PG, Gunneson EB, Hunley JA. Treatment of osteonecrosis of the
femoral head with free vascularized fibular grafting. A long-term follow-up study of one
hundred and three hips. J Bone Joint SurgAm. 1995
110. OSTEOTOMY
To rotate the necrotic or collapsing segment of
the hip out of the weight bearing zone,
replacing it with a segment of articular cartilage
of the femoral head supported by healthy
viable bone.
In addition to the biomechanical effect,
osteotomy reduce venous hypertension and
decrease intramedullary pressure.
111. Utilized for both pre- and postcollapse lesions, but
not be performed if there is acetabular involvement
Work best when the lesions are small or medium
sized with a combined necrotic angle of less than
200° or with less than 30% of femoral head
involvement.
For varus osteotomies, there should be at least 20° of
the superolateral femoral head not involved with
disease, because this area of cartilage will be
shifted into weight bearing after the osteotomy.
112. Valgus osteotomy requires normal bone and
cartilage in the central or medial aspect of the
head.
Extension can be added when the necrotic
segment is posterior
Flexion can be added if the lesion is anterior
115. Radiographs of a hip that underwent a varus
osteotomy for osteonecrosis
116. Rotational osteotomy indicated in early to
intermediate stages in which the acetabular
cartilage is relatively unaffected
Must be sufficient normal bone and cartilage in
the femoral head so that after rotation the
intact segment occupies at least 36% of the
weight-bearing surface of the acetabulum.
Contraindications include whole-head necrosis,
significant degenerative changes in the femoral
head or acetabulum, and poor general health
117. Rotational Osteotomies
In 1973, Sugioka reported transtrochanteric
anterior rotation osteotomy
More than 500 of these procedures were
performed since 1972, and Sugioka's results,
especially in hips treated before significant
femoral head collapse, were quite gratifying
Unfortunately, these results could not be
consistently duplicated by other investigators
118. Schematic of the Sugioka transtrochanteric
rotational osteotomy of the femoral head.
119. Transposition of necrotic focus of femoral head anteroinferiorly
away from weight-bearing area as a result of anterior rotation of
the femoral head. (A) before rotation and (B) after rotation. (From
Sugioka Y, Mohtai M. Osteonecrosis of the Femoral Head
120. Zhang et al
Experimentenly injected intravenous bone
marrow mesenchymal cells in rabbit and results
revealed intravenously implanted MSCs could
migrate into the femoral head of hosts, and
especially migrate directionally and survive in the
necrotic femoral heads. Thus, it is feasible and
safe to treat femoral head necrosis by intravenous
transplantation of allogeneic MSCs
Intravenous transplantation of allogeneic bone marrow mesenchymal stem
cells and its directional migration to the necrotic femoral head Zhang-hua Li
International Journal of Medical Sciences 2011
121.
122. Total hip replacement is recommended for
patients over the age of fifty years who have
any degree of symptomatic osteonecrosis or
patients over the age of forty years who have
advancedstage-IV disease or involvement of
>50% of the femoral head with limited hip
motion.
