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AVASCULAR NECROSIS
Dr. Rajesh Pattanaik,
PG dept of Radiodiagnosis
Definition
 “Cellular death of bone components
secondary to interruption of blood supply.”
 Consequent collapse of bone ...
Presentation - History
 Trauma
 Corticosteroid use
 Alcohol intake
 Medical conditions – malignancy, thrombophilia, SL...
 AGE: 3RD – 5TH DECADE
 VERY RARE IN EXTREMES OF AGE
 MALE : FEMALE = 4:1
 BILATERAL IN 50 % OF CASES
 ONSET – INSIDI...
 Pain.
- Dull boring .
- Progressive.
- Worse at night
-Limp while walking.
- Restricted hip
motion.
- Unable to sit cros...
Pathophysiology
 Affect bones with single terminal blood supply:
 Talus
 Carpals, tarsals
 Proximal humerus
 Femoral ...
Ischaemia
Death of
haemopoietic tissue -(6-12 hrs )
Death of Bone Cells ( Osteoclast, Osteoblast & Osteocytes)
(12- 48hrs)...
• Empty Osteocyte Lacunae
But
• Trabecular framework intact
Radiologically Normal Bone.
• Revasularisation- at Live-Dead marrow interface.
• Necrotic zone invaded by capillaries, fibroblasts &
macophages.
• Fib...
4 ZONES IN AVN
• A-ARTICULAR
CARTILAGE
• B-ZONE OF ISCHAMIA
• C–REPARATIVE ZONE
• D-NORMAL BONE
Vascular insufficiency to bone is of 3 types
1.Interruption to the flow of blood-
tearing of blood vessels –Trauma *
2.Emb...
PATHOGENETIC CLASSIFICATION
• TYPE 1: ARTERIAL INSUFFICIENCY
– FRACTURES
– DISLOCATIONS
– SCFE
– ART. EMBOLISM
– VASCULITI...
CAUSES
 Trauma
 Alcohol consumption
 Corticosteroid intake
 Hypercortisolism
 Cushing disease
 Hemoglobinopathies
(S...
 M/c affects => Femoral Head *
 M/c site => Anterolateral aspect (Being principal Wt.
bearing portion)
 Incidence d/t S...
BLOOD SUPPLY OF FEMORAL HEAD
lateral circumflex A.
Medial circumflex A.
BLOOD SUPPLY OF FEMORAL HEAD
 The principal sources are the Lateral Epiphyseal Vessels
(LEVs).
 LEVs Posterior Superior ...
Blood Supply in Paediatric Age Gp.
 Till 4-7 years of age, the vascular anatomy in a
transitional stage of development.
...
Mechanism of Development of AVN d/t Trauma
IMAGING
Radiological changes
21
• Stage-1: No changes are visible
• Stage-2: Disuse osteoporosis except
avascular part.
• Stage-3:...
Sequence of events
• Fragmentation : radiolucent clefts may be
seen due to necrosis of involved bone
• Mottled trabecular ...
23
• Sclerosis : with revascularisation new
bone is deposited around dead bone
resulting in increased bone density
• Subch...
24
• These cysts are usually seen in region of greatest
articular stress and are identical to those found in
degenerative ...
Radiology- sequential
Changes
• Crescent Sign
• Osteoporosis
• Sclerosis
• Cystic changes
• Loss of spherical weight
beari...
Xrays.
26
 Xray changes are “stage dependent”
 Early stages : normal film.
 Subsequently there occurs increased “
DENSI...
X RAY changes
27
Sclerosis/subchondral cysts
28
 Sclerosis
 subchondral cysts
29
30
BONE SCAN
• EARLY DIAGNOSIS NEXT TO
MRI
• USING 99MTC-SULFUR
COLLOID
• HALL MARK OF
AVASCULARITY
– PHOTOPENIC DEFECT.
• WI...
MRI
33
 MRI is most sensitive technique for early
diagnosis in Osteonecrosis
 Can diagnose AVN as early as 48 hours
 Th...
 Classic Findings:- look for focal lesion in the
anterosuperior portion of femoral head that is well
demarcated but is in...
MRI T1
image
•  signal from
ischemic marrow
• Single band like
area of low signal
intensity.
• 100% sensitivity
• 98% spe...
Double Line sign – T2
image
• A second high
signal intensity
seen within the
line seen on T1
images.
• Represent hyper
vas...
Early
FEMORAL HEAD
CHANGES
MRI - Findings
40
 Bone Marrow edema
 Double Line – Head in Head sign
 Crescent sign
 Collapse
 Joint effusion
 Invo...
T1
41
T2
42
T2 fat sat
43
44
45
CT SCAN
 CT scans show sclerosis in the central part of femoral head as an
alteration of asterisk sign.
 ACCURATELY ASSE...
Axial CT: Patient without AVN of the Femoral Head
Prominent & Thickened
but Normal Trabeculae
ASTERISK SIGN
Investigations
MRI Bone scan
CT Scan
Plain X-Ray
 Most Sensitive
 1.5-T magnet
88% sensitivity
100% specificity
94% accu...
• In the 1960s, Arlet & Ficat in France
described a 3-part staging system & in the
1970s a 4th stage was added
CLASSIFICAT...
Stage 2
Stage 3
• Moderate symptoms.
• Loss of shape
• Crescent sign
• Subchondral collapse
57
Stage 4
• Severe symptoms.
• Joint space
narrowing.
• OA changes in
acetabulum.
58
A major disadvantage was that it didn’t include any
measurement of lesion size or articular surface
involvement..
 1974, Kerboul et al noted
that the results of osteotomies
performed for osteonecrosis
depended on both the location
& th...
 0 Normal or nondiagnostic x-ray, bone scan, and MRI
 I Normal x-ray;abnormal bone scan and/or MRI, subdevided
based on ...
 IV Flattening of femoral head
A. Mild (15% of surface and 2 mm depression)
B. Moderate (15%–30% of surface or 2–4 mm dep...
 1991, The Committee on Nomenclature & Staging of the
Association Research Circulation Osseous (ARCO) endorsed
the stagin...
Class T1 T2 Definition
A Bright Intermediate Fat signal
B Bright Bright Blood signal
C Intermediate Bright Fluid or edema
...
CORONAL T2-WEIGHTED MRI
 Preserve rather than Replacing Femoral Head &
Cartilage
 Early Intervention has favorable impact on the
disease prognos...
Management principles
 Early stages (I & II):
 Bed rest & limited weight bearing .
 Bisphosphonates prevent collapse
 ...
Surgical procedures
Joint Preserving Joint Replacing
 Core
Decompression
 Various
Nonvascularized &
Vascularized Bone
Gr...
73
VARUS OSTEOTOMY WITH FLEXION OR
EXTENSION
Transposition of the necrotic focus to the ant. & inf. part of the femoral head away
from the weight-bearing area as a res...
ROTATIONAL OSTEOTOMY
Surface replacement
77
Bhumika – Non Cemented THR
Malakar post alcohol AVN Bil THR 1991
79
Thank you
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
Avascular necrosis Radiology
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Avascular necrosis Radiology

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avascular necrosis & Radiological features .

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Avascular necrosis Radiology

  1. 1. AVASCULAR NECROSIS Dr. Rajesh Pattanaik, PG dept of Radiodiagnosis
  2. 2. Definition  “Cellular death of bone components secondary to interruption of blood supply.”  Consequent collapse of bone components  Pain, loss of function of joints  Proximal epiphysis of femur most commonly affected
  3. 3. Presentation - History  Trauma  Corticosteroid use  Alcohol intake  Medical conditions – malignancy, thrombophilia, SLE, SCD  Pain – progressive, severity correlates with size of infarct  Deformity and stiffness – later stages
  4. 4.  AGE: 3RD – 5TH DECADE  VERY RARE IN EXTREMES OF AGE  MALE : FEMALE = 4:1  BILATERAL IN 50 % OF CASES  ONSET – INSIDIOUS AND CHRONIC
  5. 5.  Pain. - Dull boring . - Progressive. - Worse at night -Limp while walking. - Restricted hip motion. - Unable to sit cross legged. - Radiating to knee & Buttock 5
  6. 6. Pathophysiology  Affect bones with single terminal blood supply:  Talus  Carpals, tarsals  Proximal humerus  Femoral condyles  Proximal femur  Interruption of blood flow to bone cells
  7. 7. Ischaemia Death of haemopoietic tissue -(6-12 hrs ) Death of Bone Cells ( Osteoclast, Osteoblast & Osteocytes) (12- 48hrs) Marrow Fat (2-5 days)
  8. 8. • Empty Osteocyte Lacunae But • Trabecular framework intact Radiologically Normal Bone.
  9. 9. • Revasularisation- at Live-Dead marrow interface. • Necrotic zone invaded by capillaries, fibroblasts & macophages. • Fibrous tissue replace dead marrow & may calcifay • New osteoblasts laydown fresh bone on devitalised trabeculae. [advancing front of neo-vascularization & ossification ] CREEPING SUBSTITUTION
  10. 10. 4 ZONES IN AVN • A-ARTICULAR CARTILAGE • B-ZONE OF ISCHAMIA • C–REPARATIVE ZONE • D-NORMAL BONE
  11. 11. Vascular insufficiency to bone is of 3 types 1.Interruption to the flow of blood- tearing of blood vessels –Trauma * 2.Emboli or sludging – by rbc aggregates in -SCD fat emboli in -Pancreatitis gas bubbles in -Caisson’s disease vasculitis in - collagen disorder 3.Intraosseous compression of vessels Gaucher’s Diasease.
  12. 12. PATHOGENETIC CLASSIFICATION • TYPE 1: ARTERIAL INSUFFICIENCY – FRACTURES – DISLOCATIONS – SCFE – ART. EMBOLISM – VASCULITIS • TYPE 2: VENOUS OCCLUSION – VENOUS THROMBOSIS • TYPE 3: INTRAVASCULAR CAPILLARY OCCLUSION – SICKLE CELL DISEASE – DYSBARIC ISCHAEMIA – FAT EMBOLIS IN HYPERCORTISONISM AND ALCOHOLIM – SLE • TYPE 4: INTRA MEDULLARY FACTORS – BONE INFECTION – GAUCHER’S DISEASE – FATTY CHANGES – HYPERLIPIDAEMIA
  13. 13. CAUSES  Trauma  Alcohol consumption  Corticosteroid intake  Hypercortisolism  Cushing disease  Hemoglobinopathies (SCD;Hb S/C;Polycythemia)  Caisson disease (Dysbaric osteonecrosis)  Pancreatitis  Neoplasms  CRF  Hemodialysis  Cigarette smoking  Collagen Vascular dis.  SLE  Gout and hyperuricemia  Hypercholesterolemia  Hypercoagulable states  Hyperlipidemia  Hyperparathyroidism  Intravascular coagulation  Organ transplantation  Pregnancy  Congenital dislocation Hip  Ehlers-Danlos synd  Heredity dysostosis  Legg-Calvé-Perthes dis  Fabry disease  Gaucher disease  Giant cell arteritis  Thrombophlebitis  Idiopathic
  14. 14.  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 a Sparse vascular supply. In contrast to Hematopoietic marrow which has a rich blood supply AVASCULAR NECROSIS
  15. 15. BLOOD SUPPLY OF FEMORAL HEAD lateral circumflex A. Medial circumflex A.
  16. 16. 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
  17. 17. Blood Supply in Paediatric Age Gp.  Till 4-7 years of age, the vascular anatomy in a 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.
  18. 18. Mechanism of Development of AVN d/t Trauma
  19. 19. IMAGING
  20. 20. Radiological changes 21 • Stage-1: No changes are visible • Stage-2: Disuse osteoporosis except avascular part. • Stage-3: Subcortical zone of demineralization (in large joints, at areas of maximal stress with cortical micro fracture followed by collapse & trabecullar compression) • Stage4: Flattened articular surface (with increased subarticular density due to compressed trabeculae ) • Stage-5: Osteoarthritis with joint space narrowing.
  21. 21. Sequence of events • Fragmentation : radiolucent clefts may be seen due to necrosis of involved bone • Mottled trabecular pattern: scrutiny of trabeculae traversing the ischaemic bone demonstrates thickened irregular pattern
  22. 22. 23 • Sclerosis : with revascularisation new bone is deposited around dead bone resulting in increased bone density • Subchondral cysts : patchy well circumscribed rarefactions immediately beneath the articular cortex are frequent
  23. 23. 24 • These cysts are usually seen in region of greatest articular stress and are identical to those found in degenerative joint disease • Collapse of articular cortex this generally occurs at the region of maximal stress of involved cortex and represents a localised impaction fracture of weakened bone
  24. 24. Radiology- sequential Changes • Crescent Sign • Osteoporosis • Sclerosis • Cystic changes • Loss of spherical weight bearing dome • Partial collapse of head • Secondary Osteoarthritis
  25. 25. Xrays. 26  Xray changes are “stage dependent”  Early stages : normal film.  Subsequently there occurs increased “ DENSITY “ of the femoral head.  Crescent sign.  Femoral head collapse.  Osteoarthritis of the hip. B/l involvement of femoral head with cystic changes/sclerosis seen
  26. 26. X RAY changes 27
  27. 27. Sclerosis/subchondral cysts 28  Sclerosis  subchondral cysts
  28. 28. 29
  29. 29. 30
  30. 30. BONE SCAN • EARLY DIAGNOSIS NEXT TO MRI • USING 99MTC-SULFUR COLLOID • HALL MARK OF AVASCULARITY – PHOTOPENIC DEFECT. • WITH REVASCULARISATION. – INCREASED UPTAKE OF RADIONUCLIED – SUBSEQUENT INCREASED SCINTIGRAPHIC ACTIVITY • EARLY STAGES – COLD SPOT • LATE STAGES - HOT SPOT • SPECT IMPROVES DX ACCURACY
  31. 31. MRI 33  MRI is most sensitive technique for early diagnosis in Osteonecrosis  Can diagnose AVN as early as 48 hours  The classical finding of AVN is decrease in the normally high intensity signal of marrow.
  32. 32.  Classic Findings:- look for focal lesion in the anterosuperior portion of femoral head that is well demarcated but is inhomogeneous  T1 images => serpigineous zone of low signal intensity arround avascular area.  T2 images => double line sign => classic sign of AVN, made up of 2 concentric high and low signal bands  high-signal-intensity line may represent hypervascular granulation tissue MRI Findings
  33. 33. MRI T1 image •  signal from ischemic marrow • Single band like area of low signal intensity. • 100% sensitivity • 98% specificity
  34. 34. Double Line sign – T2 image • A second high signal intensity seen within the line seen on T1 images. • Represent hyper vascular granulation tissue
  35. 35. Early
  36. 36. FEMORAL HEAD CHANGES
  37. 37. MRI - Findings 40  Bone Marrow edema  Double Line – Head in Head sign  Crescent sign  Collapse  Joint effusion  Involvement of actabulum  Status of other hip  Marrow infiltrating disease
  38. 38. T1 41
  39. 39. T2 42
  40. 40. T2 fat sat 43
  41. 41. 44
  42. 42. 45
  43. 43. CT SCAN  CT scans show sclerosis in the central part of femoral head as an alteration of asterisk sign.  ACCURATELY ASSESS THE FEMORAL HEAD COLLAPSE. JOINT SPACE NARROWING, SCLEROSIS OSTEOPHYTE.  CT scanning is a good modality to assess the extent of the disease and calcification, but it is not as sensitive as MRI
  44. 44. Axial CT: Patient without AVN of the Femoral Head Prominent & Thickened but Normal Trabeculae ASTERISK SIGN
  45. 45. Investigations MRI Bone scan CT Scan Plain X-Ray  Most Sensitive  1.5-T magnet 88% sensitivity 100% specificity 94% accuracy  Indispensable for Accurate Staging of AVN because images clearly depict 1. Size of the lesion 2. Gross estimates of stage  Reflects Vascular Integrity  Avascular Focus may be demonstrated Early in Disease (MRI Contrast)  85% sensitivity  For Extent of Involvement e.g. Subchondral Lucencies & Sclerosis during Reparative stage  Enables detection of subchondral or cancellous # & collapse  Unable to detect disease of stage 0 or 1  Helpful in assessing flattening of the Femoral Head & asso. Degen. changes
  46. 46. • In the 1960s, Arlet & Ficat in France described a 3-part staging system & in the 1970s a 4th stage was added CLASSIFICATION & STAGING Avascular necrosis of the hip 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
  47. 47. Stage 2
  48. 48. Stage 3 • Moderate symptoms. • Loss of shape • Crescent sign • Subchondral collapse 57
  49. 49. Stage 4 • Severe symptoms. • Joint space narrowing. • OA changes in acetabulum. 58
  50. 50. A major disadvantage was that it didn’t include any measurement of lesion size or articular surface involvement..
  51. 51.  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.
  52. 52.  0 Normal or nondiagnostic x-ray, bone scan, and MRI  I Normal x-ray;abnormal bone scan and/or MRI, subdevided based on location (medial ,central or lateral) & % A. Mild (<15% of femoral head affected) B. Moderate (15%–30%) C. Severe (>30%)  II “Cystic” and sclerotic or mottled changes in femoral head without collapse or acetabular involvement. 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%) University of Pennsylvania Classification of Osteonecrosis
  53. 53.  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 changes
  54. 54.  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
  55. 55. Class T1 T2 Definition A Bright Intermediate Fat signal B Bright Bright Blood signal C Intermediate Bright Fluid or edema signal D Dark Dark Fibrosis signal Mitchell’s MRI Staging
  56. 56. CORONAL T2-WEIGHTED MRI
  57. 57.  Preserve rather than Replacing Femoral Head & Cartilage  Early Intervention has favorable impact on the disease prognosis irrespective of T/t modality used AIM OF TREATMENT
  58. 58. Management principles  Early stages (I & II):  Bed rest & limited weight bearing .  Bisphosphonates prevent collapse  Unloading osteotomies  Medullary decompression + bone grafting  Intermediate stage (III & IV):  Realignment osteototmies, decompression  Arthrodesis  Late stage (V & VI):  Analgesia, activity modification  Arthrodesis  Arthroplasties
  59. 59. Surgical procedures Joint Preserving Joint Replacing  Core Decompression  Various Nonvascularized & Vascularized Bone Grafting Procedures  Osteotomy Procedures  Total Hip Arthroplasty  Hip Resurfacing Procedures
  60. 60. 73
  61. 61. VARUS OSTEOTOMY WITH FLEXION OR EXTENSION
  62. 62. Transposition of the necrotic focus to the ant. & inf. part of the femoral head away from the weight-bearing area as a result of the ant. rotation of the head before rotation After rotation ROTATIONAL OSTEOTOMY
  63. 63. ROTATIONAL OSTEOTOMY
  64. 64. Surface replacement 77
  65. 65. Bhumika – Non Cemented THR
  66. 66. Malakar post alcohol AVN Bil THR 1991 79
  67. 67. Thank you

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