Avascular necrosis of hip

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Avascular necrosis of hip

  1. 1. Avascular Necrosis – A practical approach Girish Yeotikar Arjun Wadhwani Vinod Naneria Choithram Hospital & Research Centre, Indore, India
  2. 2. Osteonecrosis –AVN The death of cell components of bone & bone marrow from repeated interruptions or a single massive interruption of the blood supply to the bone.
  3. 3. AVN – responsible for • 15,000 new cases of AVN/year • 10% THR in USA. • 10% undisplaced # neck Femur • 30% displaced # neck Femur • 10% Dislocation Hip
  4. 4. Management protocol • Early diagnosis • Radiological evaluation • Rule out other causes • MRI • Quantification • Treatment algorithm
  5. 5. Early Diagnosis – suspicion ? • High degree of suspicion in a patient C/o anterior HIP pain, especially with:- H/o Cortisone – For -- Skin, Eye, Liver, Asthma, RA, Weight gain, PID H/o Alcohol abuse Traumatic - # N/F, D/ of F, # Acetabulum Hemoglobinopathy – Sickle / Myelo-infiltrating Even with normal x-rays
  6. 6. Radiology- sequential Changes • Crescent Sign • Osteoporosis • Sclerosis • Cystic changes • Loss of spherical weight bearing dome • Partial collapse of head • Secondary Osteoarthritis
  7. 7. Magnetic Resonance Imaging • After radiological evaluation • Cases of Ant. Hip pain + nil / minimal X- ray changes, ask for MRI • Rule out other causes of AVN Sickle cell, RA, Gout, CRF,SLE & other collagen disorders.
  8. 8. MRI - Findings • Bone Marrow edema • Double Line – Head in Head sign • Crescent sign • Collapse • Joint effusion • Involvement of actabulum • Status of other hip • Marrow infiltrating disease
  9. 9. MRI T1 image •  signal from ischemic marrow • Single band like area of low signal intensity. • 100% sensitivity • 98% specificity
  10. 10. Double Line sign – T2 image • A second high signal intensity seen within the line seen on T1 images. • Represent hyper vascular granulation tissue
  11. 11. Pearls & pitfalls on MRI • Involve antero-lateral aspect. • Articular cartilage intact initially. • Sagittal images are more accurate. • Double line sign may be –ve in 20%. • Collapse correspond to Ficat 3. • TOH may be Subchondral femoral head stress fractures.
  12. 12. Normal AVN TOH
  13. 13. Diagnosis Early Stage Osteonecrosis Direct Risk Factors Associated Risk Factors Traumatic fracture / dislocation Corticosteroid use Sickle cell disease Alcohol abuse Radiation Tobacco abuse Chemotherapy SLE Myeloproliferative disorders Organ transplant Thalassemia Gastrointestinal disorder Caisson disease Pregnancy, Genetic inheritance, Coagulation deficiency
  14. 14. Pathophysiology • Acute vascular interruption: • Fracture • Dislocation • Altered lipid metabolism: • Corticosteroids. • Alcohol • Intravascular coagulation: • Heamoglobinopathy, familial thrombophilia, hypercholesterolemia, allograft organ rejection,, infection, malignancy, or pregnancy.
  15. 15. Time Line • Death of hematopoietic cells - Ischemic insult – Bone scan + 6 -12 hours • Death of Osteocytes 12- 48 hours • Bone scan becomes negative once remodeling occur. • MRI will become positive after 5 days due to death of fat cells, but it will remain positive till complete healing. • Focal MR abnormality and diffuse marrow edema can been by 6-8weeks Histology is the only method to confirm AVN Empty lacuna – dead osteocytes
  16. 16. Preventive measures • Judicial use of steroids • Use of Statin in cases of short/long term high dosage of steroids. • Public awareness for avoiding drug for rapid weight gain and decrease libido (anabolic steroids). • Discourage excessive alcohol and smoking. • Patients at high risk informed about the possibility of AVN, & to report symptoms as soon as possible to facilitate early diagnosis and treatment.
  17. 17. Pharmacological Agents • lipid-lowering agents, • Anticoagulants, Prostacyclin analogs, may work by inhibiting aggregation of platelets, thus enhancing blood flow to ischemic bone areas and potentially promoting healing. • Statins, is based on the association of high levels of blood lipids and an increased risk of the development of osteonecrosis. • Bisphosphonates to decrease osteoclastic activity and permit bone formation via the osteoblastic process.
  18. 18. Pharmacological Agents • The clinical failure rates for the various pharmacological therapies have ranged from 0% to 10%. • In one of these studies, Pritchett reported that the prevalence of osteonecrosis was only 1% in patients who were receiving corticosteroid therapy and who received concurrent statin therapy. • While the results of the pharmacological studies appear promising, the reported results were limited to only short-term to midterm follow-up.
  19. 19. Quantification of the damage • On radiological evaluation & MRI evaluation: • Disease is quantified:- • Site of involvement • Size of involvement • Type of involvement • Bone marrow edema • Cystic • Sclerotic • combination
  20. 20. Staging / Grading --- too many • Ficat Radiological • Steinberg Quantification • Enneking's Stages of Osteonecrosis • Marcus and Enneking System • Japanese criteria Location • Sugioka Radiological • University Of Pennsylvania System • Association Research Classification Osseous Committee (ARCO)-- Combination
  21. 21. Stage Clinical Features Radiographs • 0 Preclinical 0 0 • 1 Preradiographic + 0 • 2 Precollapse + Diffuse Porosis, Sclerosis, Cysts • Transition: Flattening, Crescent Sign • 3 Collapse ++ Broken Contour of Head Certain Sequestrum, Joint Space Normal • 4 Osteoarthritis +++ Flattened Contour Decreased Joint Space , Collapse of Head Ficat Stages of Bone Necrosis
  22. 22. Association Research Circulation Osseous quantification
  23. 23. Relationship with weight bearing dome
  24. 24. Japanese Investigation Committee Type 1 – Line of Demarcation In relation to Wt.bearing Type 2- Partial Collapse Type 3 Cyst A- central B peripheral
  25. 25. Kerboul:- combined necrotic angle – AP LAT
  26. 26. Factors which affects decision : • Cause of AVN • Sickle • Post Traumatic / # / D / Non union • Post Radiation • Age • CRF • Staging / quantification • Cortisone • Alcohol • Available technology • Cost of Treatment
  27. 27. Mont and Hungerford JBJS 77A: 459-474,1995. • 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) • Rates of preservation of the femoral head: Stage 1 35% Stage 2 31% Stage 3 13% Natural History
  28. 28. • Rates of preservation of the femoral head: Core Decomp. No Rx Stage 1 84% 35% Stage 2 65% 31% Stage 3 47% 13% Core decompression Statistics
  29. 29. Stulberg et al CORR 186: 137-153, 1991 Randomised prospective study, 55 hips in 36 pts Good Results CD No Tx • Stage 1 70% 20% • Stage 2 71% 0% • Stage 3 73% 10%
  30. 30. Kaplan-Meier survival curves Core decompression of 128 femoral heads in 90 pts with Ficat 1,2 or 3 disease Stage 5 yr 10 yr 15 yr No Further Surgery Needed 1 100% 96% 90% 88% 2 85% 74% 66% 72% 3 58% 35% 23% 26% Despite good clinical results 56% of hips progressed at least 1 Ficat stage Core decompression with electrical stimulation results ~ the same as core decompression alone Conclusion: Core decompression delays the need for THR
  31. 31. Kaplan-Meier survival curves Free vascularized fibula grafting Stage requiring THR at 5 years 2 11% 3 23% 4 29% Results are for better than core decompression alone.
  32. 32. Proximal Femoral Osteotomy Intact weight bearing area after transposition %Success  60%, 100%  36%, - 59% 93%  21% - 35% 65% < 20% 29% More normal bone at wt. bearing area Better the result of Osteotomy
  33. 33. Irrespective of Classifications Basic questions for treatment? • How early to interfere? • How much to interfere? • Can we wait? • When to start , if at all, Bisphosphonate? Head collapsed – Head not collapsed Preservation or sacrifice
  34. 34. The basic question ? • Head preservation – without collapse • No Tx • Drilling alone • Core decompression • CD + Cancellous / free fibula graft • CD + Muscle pedicle graft • CD + vascularized fibula graft
  35. 35. The basic question ? • Head preservation – with collapse • Varus osteotomy • Valgus osteotomy • Sugiako anterior rotation osteotomy
  36. 36. The basic question ? • Head sacrifice – • Surface replacement (Birmingham's) • Non – cemented THR • Cemented THR • Cemented / Non cemented Bipolar • Non cemented AMP • Girdle Stone – Excision arthroplasty
  37. 37. Pre-Collapse Hips • Check extent of lesion If less than 30% -core decompression • greater than 30% - can consider core/electrical stimulation but needs evaluation for post-collapse methods depending on age, compliance, ongoing disease, etc. Guide-lines for management
  38. 38. Pre-Collapse Hips Location of lesion Type A (medial) - observation with periodic followup i. Type B,C - Core decompression Other considerations: i. Diagnosis: SLE do worse ii. Continued Steroid / Alcohol : Do Worse iii. Age and compliance Guide-lines for management
  39. 39. Strut Grafting Fibula Grafting • Decompression of Femoral Head • Removal of Necrotic Bone • Grafting of defect with cancellous graft • Viable cortical Bone strut to support subchondral bone. • Age 20 – 50, stage 2 – 4
  40. 40. Surgery - Core decompression • Improves circulation by decreasing intramedullary pressure and preventing further ischemia and progressive joint destruction. • The best results vary from 34-95%, which is significantly better than results of conservative treatment. • The best results are obtained when treating patients with early AVN (precollapse). • Core decompression is also effective for pain control.
  41. 41. Surgery - Core decompression + BG • Bone graft options include • structural cortical strut • Cancellous bone graft • Muscle-pedicle vascularized bone graft • Free vascularized fibular graft.
  42. 42. Surgery - Core decompression + BG • Bone grafting is combined with the following: • Core decompression, which may interrupt the cycle of ischemia • Excision of sequestrum, which may inhibit revascularization of the femoral head. • Period of limited weight bearing. • The best results have been reported with free vascularised bone grafts. Success rates of 70% and 91% have been reported in 2 small series.
  43. 43. Advantages • Advantages of free vascularized grafts compared to total hip arthroplasty include the following: • Healed femoral head may allow more activity. • No foreign body–associated complications occur. • If performed during early AVN, lifelong survival of the femoral head is possible. • The patient has the option of total hip arthroplasty in the future.
  44. 44. Disadvantages • Disadvantages of free vascularized grafts include the following: • Longer period of recovery • Less complete pain relief. • Variable success rate • Lack of effectiveness in advanced disease
  45. 45. 35 yr. F, post delivery 1992
  46. 46. FU - post delivery pelvis July 2000
  47. 47. 35 years F, post delivery AVN - 1988
  48. 48. Same pt. post delivery AVN July 2000
  49. 49. 55, Male alcohol - AVN
  50. 50. Same pt. Fibula strut graft
  51. 51. FU of the same Pt.
  52. 52. AVN – Post Hip dislocation 2001
  53. 53. Post Dislocation FU- 2006
  54. 54. 2006
  55. 55. Girdhar Gupta 2004Post cortisone 25 M - 2004
  56. 56. Post cortisone 25 M
  57. 57. Post cortisone 25 M - 2005
  58. 58. Post cortisone 25 M -2006
  59. 59. Post cortisone 30 M - 2003
  60. 60. Post cortisone 30 M
  61. 61. Post cortisone 30 M 2009
  62. 62. Post cortisone 30 M 2009
  63. 63. Post cortisone 35 M 2001
  64. 64. Post cortisone 30 M – Fibula strut graft
  65. 65. 2008 2003 Post cortisone 30 M - 2008
  66. 66. 2008
  67. 67. R. V. - 2001
  68. 68. MRI-R. 27 F, 2001
  69. 69. R.V. After 6 months
  70. 70. R.V. After one year
  71. 71. S.L. 40 M – post Cortisone
  72. 72. S.L. 40 M – post Cortisone Bilateral grafting
  73. 73. Ashok 2001
  74. 74. Pre OP Post OP
  75. 75. D.C. 3 yrs PO - 2001
  76. 76. 2008 2008 D.C. 3 yrs PO - 2008
  77. 77. 2008
  78. 78. 2008
  79. 79. G.24 M 2000
  80. 80. 2008
  81. 81. 2011
  82. 82. 2011
  83. 83. P.G. 30 M, cortisone induced - AVN Cancellous Bone grafting
  84. 84. 2003 – P.G.
  85. 85. 2007 – P. G.
  86. 86. 2007
  87. 87. Technique of Cancellous Bone grafting - Localization in C-arm - Guide wire in to lesion - Cannulated drilling - Curettage - Interlocking sleeve - Cancellous iliac graft - Packing with impactor/screw driver
  88. 88. Vinod Nagar
  89. 89. After 3 months
  90. 90. M. 50 M CRF transplant left hip 1997 core decompression 3 years post op Oct. 2000
  91. 91. Vascularised Free Fibula Graft “Healing Construct” • Decompression of Femoral Head • Removal of Necrotic Bone • Grafting of defect with cancellous graft • Viable cortical Bone strut to support subchondral bone. • Age 20 – 50, stage 2 – 4
  92. 92. Summaries of cases with head preservation by free fibula grafting
  93. 93. Post-Collapse Hips 1.Check extent of lesion i. less than 200 degrees Kerboul combined necrotic angles or less than 30% head involvement - consider osteotomy: ii. 20 degrees laterally preserved cartilage-varus osteotomy iii. not above- valgus osteotomy iv.greater than 200 degrees; consider bone grafting. Guide-lines for management
  94. 94. Osteotomy • Several osteotomy procedures have been tried with variable success. • Intertrochanteric osteotomies have been performed in patients with posttraumatic AVN.
  95. 95. Osteotomies • Transtrochanteric rotational osteotomy involves rotation of the femoral head and neck on the longitudinal axis. The necrotic anterosuperior part of the femoral head becomes posterior, and the weight- bearing force is transmitted to what was previously the posterior articular surface, which is not involved in the ischemic process. • In 1992, Sugano and colleagues reported excellent results in 56% of patients who underwent this procedure.[13] Transtrochanteric rotational osteotomy is technically demanding.
  96. 96. K. K. 35 M AVN 1983 Osteotomy
  97. 97. 19891983 K. K. 35 M AVN
  98. 98. K. K. Aug. 2000
  99. 99. R. J. 30 f post delivery left hip 1985
  100. 100. R.J. post delivery left hip 1989
  101. 101. M.- 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
  102. 102. 2009
  103. 103. 2009
  104. 104. 2009
  105. 105. A. 22 f CRF transplanted 2000
  106. 106. After 2 years
  107. 107. Replacement - options • Hemiarthroplasty • Bipolar arthroplasty • Surface replacement arthroplasty. • Newer material for THR ceramic on ceramic • Non cemented / cemented THR
  108. 108. Post collapse Late-Collapse - symptomatic treatment till resurfacing or THR necessary Guide-lines for management
  109. 109. K. - 1992
  110. 110. K. 35 f 1999 after removal plate
  111. 111. Bipolar Replacement on right side
  112. 112. AMP Replacement on left side 2002
  113. 113. 2011
  114. 114. 2011
  115. 115. S, 35 F 2008 2009
  116. 116. 2009 2011
  117. 117. 2011 2011
  118. 118. Total hip arthroplasty • Most patients with advanced disease (stage III and above) require total hip arthroplasty. • Total hip arthroplasty provides excellent pain relief for many years, although most young patients require repeat surgery.
  119. 119. Total hip arthroplasty • With high failure rates (10-50% after 5 y), patients with AVN will probably need a second total hip arthroplasty during their lifetime.
  120. 120. M. post alcohol AVN Bil THR 1991
  121. 121. M. Bil. THR 9 year post-op. Nov 2000
  122. 122. B. 19 yrs, F, post cortisone
  123. 123. Non Cemented THR
  124. 124. AVN – Post # Neck Femur 1988 2002 20061990
  125. 125. R. B. – 45 F
  126. 126. R. B. – 45 F
  127. 127. Bhalchand AMP – Rt - 1988 THR – Lt - 1991
  128. 128. 2005 Poly wear
  129. 129. 2007
  130. 130. THR removed due to persistent pain cause? AMP still working
  131. 131. Study/year/ design Technique Hips Precollapse Failures Postcollapse Failures Maniwa et al. CD w/wo NVG 26 26 8 (30.8%) Steinberg et al. D/NVG/EStim 312 198 63 (31.8%) 105 48 45.7%) Gangji et al.) CD 8 8 2 (25%) CD/BMG 10 10 0 (0%) Hernigou et al CD/BMG 189 136 23 (16.9%) 7 7 (100%) Yang et al. CD/BLAC 56 48 5 (10.4%) 8 4 (50%) Tsao et al. CD/TR 113 94 18 (19.1%) 19 4 (21%) Shuler et al. CD/TR 22 22 3 (13.6%) Kim et al. VFG 23 10 1 (10%) 13 7 (53.8%) NVFG 3 10 5 (50%) 13 11 (84.6%)
  132. 132. Psychosocial - AVN • Drugs for gain in weight. • Steroid like drugs • Herbal/ Aurvedic/ Chinese/ • Drugs for improved performance in sex. These drugs may be mixed with steroids which may cause AVN
  133. 133. Weight gain medicines
  134. 134. Performance improving drugs
  135. 135. Carry Home Message – Anterior Hip pain + Cortisone • Anterior hip pain in a young adult male should be consider as AVN till proved otherwise. • History of Cortisone may be in very small dosage or for a very short time can cause AVN in sensitive patient who have deficiency of Cytochrome P450 3A (steroid-metabolizing hepatic enzyme). • suppression of CYP3A activity significantly increased vulnerability to steroid-induced osteonecrosis, while increased CYP3A activity reduced this vulnerability.
  136. 136. Carry Home Message – Management Phylosophy • Early diagnosis • Early decompression • Calcellous bone graft • Bisphosphonate • Osteotomy • Replacement arthroplasty
  137. 137. • Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 32 years. • It is intended for use only by the students of orthopaedics. • Many GIF files are taken from Internet. • Views and opinions expressed in this presentation are personal. • Depending upon the x-rays and clinical presentations viewers can make their own opinion. • For any confusion please contact the sole author for clarification. • Every body is allowed to copy or download and use the material best suited to him. • I am not responsible for any controversies arise out of this presentation. • For any correction or suggestion or copy right violation please contact naneria@yahoo.com DISCLAIMER
  138. 138. Thank You The End Of AVN Story

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