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

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