Avascular necrosis hip

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A devastating disease of hip, its causes, and management protocol

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  • Avascular necrosis hip

    1. 1. Avascular Necrosis – Femoral Head A practical approach Vinod Naneria Girish Yeotikar Arjun Wadhwani
    2. 2. - Osteonecrosis –AVN <ul><li>The death of cell components of bone & bone marrow from repeated interruptions or a single massive interruption of the blood supply to the bone. </li></ul>
    3. 3. Management protocol <ul><li>Early diagnosis </li></ul><ul><li>Radiological evaluation </li></ul><ul><li>Rule out other causes </li></ul><ul><li>MRI </li></ul><ul><li>Quantification </li></ul><ul><li>Treatment algorithm </li></ul>
    4. 4. Early Diagnosis – suspicion ? <ul><li>High degree of suspicion in a patient C/o anterior HIP pain, Especially with:- </li></ul><ul><li>H/o Cortisone – Skin, Eye, Liver, Asthma, </li></ul><ul><li>RA, Weight gain, PID – </li></ul><ul><li>H/o Alcohol abuse </li></ul><ul><li>Traumatic - # N/F, D/ of F, # Acetabulum </li></ul><ul><li> Hemoglobinopathy – Sickle / Myelo-infiltrating </li></ul>
    5. 5. Other causes <ul><li>Pregnancy </li></ul><ul><li>Renal Diseases </li></ul><ul><li>Radiation </li></ul><ul><li>Gout / Collagen disorder </li></ul><ul><li>Gaucher’disease </li></ul><ul><li>Dysbarism </li></ul><ul><li>Idiopathic </li></ul>
    6. 6. Radiology- sequential Changes <ul><li>Crescent Sign </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Sclerosis </li></ul><ul><li>Cystic changes </li></ul><ul><li>Loss of spherical weight bearing dome </li></ul><ul><li>Partial collapse of head </li></ul><ul><li>Secondary Osteoarthritis </li></ul>
    7. 8. Bilateral Cystic changes With patchy sclerosis
    8. 9. The second step - MRI <ul><li>After radiological evaluation </li></ul><ul><li>Cases of Ant. Hip pain + nil / minimal X-ray changes, ask for MRI </li></ul><ul><li>Rule out other causes of AVN </li></ul><ul><ul><li>Sickle cell, RA, Gout, CRF etc. </li></ul></ul>
    9. 10. MRI - Findings <ul><li>Bone Marrow edema </li></ul><ul><li>Double Line – Head in Head sign </li></ul><ul><li>Crescent sign </li></ul><ul><li>Collapse </li></ul><ul><li>Joint effusion </li></ul><ul><li>Involvement of actabulum </li></ul><ul><li>Status of other hip </li></ul><ul><li>Marrow infiltrating disease </li></ul>
    10. 11. MRI T1 image <ul><li> signal from ischemic marrow </li></ul><ul><li>Single band like area of low signal intensity. </li></ul><ul><li>100% sensitivity </li></ul><ul><li>98% specificity </li></ul>
    11. 12. Double Line sign – T2 image <ul><li>A second high signal intensity seen within the line seen on T1 images. </li></ul><ul><li>Represent hyper vascular granulation tissue </li></ul>
    12. 13. Early
    13. 14. Late
    14. 15. Quantification of the damage <ul><li>On radiological evaluation & MRI evaluation: </li></ul><ul><li>Disease is quantified:- </li></ul><ul><ul><li>Site of involvement </li></ul></ul><ul><ul><li>Size of involvement </li></ul></ul><ul><ul><li>Type of involvement </li></ul></ul><ul><ul><ul><li>Bone marrow edema </li></ul></ul></ul><ul><ul><ul><li>Cystic </li></ul></ul></ul><ul><ul><ul><li>Sclerotic </li></ul></ul></ul><ul><ul><ul><li>combination </li></ul></ul></ul>
    15. 16. Staging / Grading --- too many <ul><li>Ficat Radiological </li></ul><ul><li>Steinberg Quantification </li></ul><ul><li>Enneking's Stages of Osteonecrosis </li></ul><ul><li>Marcus and Enneking System </li></ul><ul><li>Japanese criteria Location </li></ul><ul><li>Sugioka Radiological </li></ul><ul><li>University Of Pennsylvania System </li></ul><ul><li>Association Research Classification Osseous Committee (ARCO)-- Combination </li></ul>
    16. 17. <ul><li>Stage Clinical Features Radiographs </li></ul><ul><li>0 Preclinical 0 0 </li></ul><ul><li>1 Preradiographic + 0 </li></ul><ul><li>2 Precollapse + Diffuse Porosis, Sclerosis, Cysts </li></ul><ul><li>Transition: Flattening, Crescent Sign </li></ul><ul><li>3 Collapse ++ Broken Contour of Head Certain Sequestrum, Joint Space Normal </li></ul><ul><li>4 Osteoarthritis +++ Flattened Contour Decreased Joint Space Collapse of Head </li></ul>Ficat Stages of Bone Necrosis
    17. 18. Association Research Circulation Osseous quantification
    18. 19. Relationship with weight bearing dome
    19. 20. Japanese Investigation Committee Type 1 – Line of Demarcation In relation to Wt.bearing Type 2- Partial Collapse Type 3 Cyst A- central B peripheral
    20. 21. Kerboul:- combined necrotic angle – AP LAT
    21. 22. The basic question ? <ul><li>Head preservation – without collapse </li></ul><ul><ul><li>No Tx </li></ul></ul><ul><ul><li>Drilling alone </li></ul></ul><ul><ul><li>Core decompression </li></ul></ul><ul><ul><li>CD + Cancellous / free fibula graft </li></ul></ul><ul><ul><li>CD + Muscle pedicle graft </li></ul></ul><ul><ul><li>CD + vascularized fibula graft </li></ul></ul>
    22. 23. The basic question ? <ul><li>Head preservation – with collapse </li></ul><ul><ul><li>Varus osteotomy </li></ul></ul><ul><ul><li>Valgus osteotomy </li></ul></ul><ul><ul><li>Sugiako anterior rotation osteotomy </li></ul></ul>
    23. 24. The basic question ? <ul><li>Head sacrifice – </li></ul><ul><ul><li>Surface replacement (Birmingham's) </li></ul></ul><ul><ul><li>Non – cemented THR </li></ul></ul><ul><ul><li>Cemented THR </li></ul></ul><ul><ul><li>Cemented Bipolar </li></ul></ul><ul><ul><li>AMP </li></ul></ul><ul><ul><li>Girdle Stone – Excision arthroplasty </li></ul></ul>
    24. 25. Factors which affects decision : <ul><li>Cause of AVN </li></ul><ul><ul><li>Sickle </li></ul></ul><ul><ul><li>Post Traumatic / # / D / Non union </li></ul></ul><ul><ul><li>Post Radiation </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>CRF </li></ul></ul><ul><li>Staging / quantification </li></ul><ul><li>Cortisone </li></ul><ul><li>Alcohol </li></ul><ul><li>Available technology </li></ul><ul><li>Cost of Treatment </li></ul>
    25. 26. <ul><li>Mont and Hungerford JBJS 77A: 459-474,1995. </li></ul><ul><li>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) </li></ul><ul><li>Rates of preservation of the femoral head: </li></ul><ul><li>Stage 1 35% </li></ul><ul><li>Stage 2 31% </li></ul><ul><li>Stage 3 13% </li></ul>Natural History
    26. 27. <ul><li>Rates of preservation of the femoral head: </li></ul><ul><li>  Core Decomp. No Rx </li></ul><ul><li>Stage 1 84% 35% </li></ul><ul><li>Stage 2 65% 31% </li></ul><ul><li>Stage 3 47% 13% </li></ul>Core decompression Statistics
    27. 28. <ul><li>Stulberg et al CORR 186: 137-153, 1991 Randomised prospective study, 55 hips in 36 pts </li></ul><ul><li>Good Results CD No Tx </li></ul><ul><li>Stage 1 70% 20% </li></ul><ul><li>Stage 2 71% 0% </li></ul><ul><li>Stage 3 73% 10% </li></ul>
    28. 29. Kaplan-Meier survival curves <ul><li>Core decompression of 128 femoral heads in 90 pts with Ficat 1,2 or 3 disease </li></ul><ul><li>Stage 5 yr 10 yr 15 yr No Further Surgery Needed </li></ul><ul><li>100% 96% 90% 88% </li></ul><ul><li>85% 74% 66% 72% </li></ul><ul><li>58% 35% 23% 26% </li></ul><ul><li>Despite good clinical results 56% of hips progressed at least 1 Ficat stage </li></ul><ul><li>  Core decompression with electrical stimulation results ~ the same as core decompression alone </li></ul><ul><li>Conclusion: Core decompression delays the need for THR </li></ul>
    29. 30. Kaplan-Meier survival curves Free vascularized fibula grafting <ul><li>Stage requiring THR at 5 years </li></ul><ul><li>2 11% </li></ul><ul><li>3 23% </li></ul><ul><li>4 29% </li></ul><ul><li>Results are for better than core decompression alone. </li></ul>
    30. 31. Proximal Femoral Osteotomy <ul><li>Intact weight bearing </li></ul><ul><li>area after transposition %Success </li></ul><ul><li>60%, 100% </li></ul><ul><li>36%, - 59% 93% </li></ul><ul><li>21% - 35% 65% </li></ul><ul><li>< 20% 29% </li></ul>More normal bone at wt. bearing area Better the result of Osteotomy
    31. 32. <ul><li>Pre-Collapse Hips </li></ul><ul><li>Check extent of lesion If less than 30% -core decompression </li></ul><ul><li>greater than 30% - can consider core/electrical stimulation but needs evaluation for post-collapse methods depending on age, compliance, ongoing disease, etc. </li></ul>Guide-lines for management
    32. 33. <ul><li>Pre-Collapse Hips </li></ul><ul><li>Location of lesion Type A (medial) - observation with periodic followup </li></ul><ul><li>Type B,C - Core decompression </li></ul><ul><li>Other considerations: </li></ul><ul><li>Diagnosis: SLE do worse </li></ul><ul><li>Continued Steroid: Do Worse </li></ul><ul><li>Age and compliance </li></ul>Guide-lines for management
    33. 34. <ul><li>Post-Collapse Hips </li></ul><ul><ul><li>Check extent of lesion </li></ul></ul><ul><ul><ul><li>less than 200 degrees Kerboul combined necrotic angles or less than 30% head involvement - consider osteotomy: </li></ul></ul></ul><ul><ul><ul><li>20 degrees laterally preserved cartilage-varus osteotomy </li></ul></ul></ul><ul><ul><ul><li>not above- valgus osteotomy </li></ul></ul></ul><ul><ul><ul><li>greater than 200 degrees; consider bone grafting. </li></ul></ul></ul>Guide-lines for management
    34. 35. <ul><li>Post collapse </li></ul><ul><li>Late-Collapse - symptomatic treatment till resurfacing or THR necessary </li></ul>Guide-lines for management
    35. 36. Vascularised Free Fibula Graft “Healing Construct ” <ul><li>Decompression of Femoral Head </li></ul><ul><li>Removal of Necrotic Bone </li></ul><ul><li>Grafting of defect with cancellous graft </li></ul><ul><li>Viable cortical Bone strut to support subchondral bone. </li></ul><ul><li>Age 20 – 50, stage 2 – 4 </li></ul>
    36. 38. Strut Grafting Fibula Grafting <ul><li>Decompression of Femoral Head </li></ul><ul><li>Removal of Necrotic Bone </li></ul><ul><li>Grafting of defect with cancellous graft </li></ul><ul><li>Viable cortical Bone strut to support subchondral bone. </li></ul><ul><li>Age 20 – 50, stage 2 – 4 </li></ul>
    37. 39. Summaries of cases with head preservation by free fibula grafting
    38. 40. Firoza 35 f post delivery 1992
    39. 41. Firoza 35 f post delivery pelvis July 2000
    40. 42. Kanti 35 f post delivery AVN 1988
    41. 43. Kanti 35 f post delivery AVN July 2000
    42. 44. Upadhyay rt hip
    43. 45. Upadhyay
    44. 46. Upadhayay after one year
    45. 47. Bharat post posterior dislocation
    46. 48. Bharat after one year
    47. 49. Jakir post cortisone cystic lesion
    48. 50. Jakir after fibula grafting
    49. 51. Rajendra
    50. 52. Fibula grafting
    51. 53. Romi varma
    52. 54. MRI-Romi
    53. 56. After 6 months
    54. 57. After one year
    55. 58. Shyamlal
    56. 59. Bilateral grafting
    57. 60. Ashok 2001
    58. 61. Pre OP Post OP
    59. 63. Chandu Chandu Rane 1 / 2003 Chandu Rane 12 / 2003
    60. 64. Kamal 30 m
    61. 65. Deep chand 3 yrs PO
    62. 66. Kamal Kishor 35 M AVN 1983 Osteotomy
    63. 67. Kamal Kishor 35 M AVN 1989 1983
    64. 68. Kamal Kishor Aug.2000
    65. 69. Rekha 30 f post delivery left hip 1985
    66. 70. Rekha 30 f post delivery left hip 1989
    67. 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 Osteotomy
    68. 72. Archna 22 f CRF transplanted sept 2000
    69. 73. Archna 22 f CRF transplanted sept 2000 left hip free fibula grafting
    70. 74. Archna 22 f CRF transplanted Sept 2000 rt.hip AM Prosthesis
    71. 76. After 2 years
    72. 77. Rajesh 28 M CRF Transplant rt.hip AVN
    73. 78. Rajesh 28 M CRF Transplant rt.hip AVN core decompression FU 2/12 Nov 2000
    74. 79. Core decompression failed
    75. 82. Modi 50 M CRF transplant left hip 1997
    76. 83. Modi 50 M CRF transplant left hip 1997
    77. 84. Modi 50 M CRF transplant left hip 1997
    78. 85. Modi 50 M CRF transplant left hip core decompression 3 years post op oct 2000
    79. 86. Replacement - options <ul><li>Hemiarthroplasty </li></ul><ul><li>Bipolar arthroplasty </li></ul><ul><li>Surface replacement arthroplasty. </li></ul><ul><li>Newer material for THR ceramic on ceramic </li></ul><ul><li>Non cemented / cemented THR </li></ul>
    80. 87. Krishna
    81. 88. Krishna 35 f
    82. 90. THR <ul><li>Patient aged 50 & more </li></ul><ul><li>Advance osteoarthritis and reduction of joint space. </li></ul><ul><li>Radiation necrosis </li></ul><ul><li>Result less than Ideal. – necrotic bone </li></ul><ul><li>Poor in Sickle cell disease. </li></ul><ul><li>Cementless are superior over cemented THR </li></ul>
    83. 91. Malakar post alcohol AVN Bil THR 1991
    84. 92. Malakar post alcohol AVN Bil THR 9 year postop Nov 2000
    85. 93. Bhumika 19 yrs
    86. 94. Bhumika – Non Cemented THR
    87. 96. Thank You The End Of AVN Story

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