This document discusses avascular necrosis (AVN), including:
- Causes of AVN such as corticosteroid use, alcohol abuse, and trauma
- Management involves early diagnosis via imaging like MRI and treatment based on staging, with options ranging from observation to core decompression and bone grafting for pre-collapse cases or osteotomy for some post-collapse cases
- Surgical techniques are described for core decompression with or without bone grafting to improve blood flow and support the femoral head, as well as various osteotomies to redistribute weight bearing for some collapsed cases
- Case studies demonstrate outcomes of these treatments in preserving femoral heads or delaying total hip replacement
Madelung deformity is an abnormality of the palmar ulnar part of the distal radial physis in which progressive ulnar and volar tilt develops at the distal radial articular surface, with dorsal subluxation of the distal ulna.
Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment
This is a short presentation on avascular necrosis of femoral head. This presentation gives brief description of causes of AVN, investigations and modes of treatment options available.
AVN TREATMENT IN HYDERABAD
Core decompression for AVN
Stem cell treatment for AVN
Surgery for AVN
Avascular necrosis treatment options
Hip replacement in hyderabad
Hip specialist in hyderabad
Hip surgery in hyderabad
Total hip replacement in hyderabad
cemented hip replacement
uncemented hip replacement in hyderabad
ceramic hip replacement
delta motion hip
ceramic on ceramic hip replacement
metal on poly hip replacement
affordable hip replacement in hyderabad
Madelung deformity is an abnormality of the palmar ulnar part of the distal radial physis in which progressive ulnar and volar tilt develops at the distal radial articular surface, with dorsal subluxation of the distal ulna.
Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment
This is a short presentation on avascular necrosis of femoral head. This presentation gives brief description of causes of AVN, investigations and modes of treatment options available.
AVN TREATMENT IN HYDERABAD
Core decompression for AVN
Stem cell treatment for AVN
Surgery for AVN
Avascular necrosis treatment options
Hip replacement in hyderabad
Hip specialist in hyderabad
Hip surgery in hyderabad
Total hip replacement in hyderabad
cemented hip replacement
uncemented hip replacement in hyderabad
ceramic hip replacement
delta motion hip
ceramic on ceramic hip replacement
metal on poly hip replacement
affordable hip replacement in hyderabad
Avascular necrosis (AVN) or Aseptic Necrosis of the hip is caused by a disruption to the hip’s blood supply which results in the deterioration and often collapse of the ball of the thigh bone (femoral head). Early identification and treatment of the condition increases the likelihood that a patient’s hip will recover. Surgery may be required in severe cases to repair or revascularize (restore circulation) the hip or to replace the hip in neglected/end stage cases.
http://www.davidsfeldmanmd.com/specialties/avascular-necrosis-hip
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case StudyDavid S. Feldman, MD
David is an avid hiker who fell and fractured his femoral neck during a hike. He underwent a successful surgery which fixed his femoral neck but later developed avascular necrosis of the hip. I ultimately recommended a multi-faceted course of treatment that included bisphosphonates, core decompression, BMP/Calcium phosphate, and arthrodiastasis. This course of treatment has successfully resolved his avascular necrosis of the hip and prevented the collapse of his femoral head.
http://www.davidsfeldmanmd.com/patient-education/case-studies/david-femoral-neck-fracture-w-avascular-necrosis-hip
Avascular necrosis of Hip - treatment modalities and current concepts.pptxVivek Jadawala
Slide 1 - Treatment modalities of Avascular Necrosis of Hip
JOURNAL CLUB PRESENTATION
Dr. Vivek Jadawala
PGY-3, Dept. of Orthopaedics,
JNMC, DMIHER
Slide 2 - image
slide 3 - image
slide 4 - Osteonecrosis of Hip - Osteonecrosis is death of living elements of involved bone (cells including marrow) with progressive destruction and alteration of bone architecture as a result of compromised vascularity.
Usually aseptic but may be incited by loss of vascularity from infection.
Slide 5 - Epidemiology - Male > Female
Average age group – 35 to 50 years
Bilateral Hip joints – 80 % of the cases
Most common site – Antero-lateral aspect of femoral head
Slide 6 - Blood supply of femoral head
Slide 7 - Classification of AVN: Ficat and Arlet -STAGE 0 :
X-ray : normal
MRI: normal
clinical symptoms: nil
STAGE I :
X-ray : normal or minor osteopenia
MRI: edema
bone scan: increased uptake
clinical symptoms: pain typically in the groin
Slide 8 - Stage I
Slide 9 - Stage II -
X-ray: mixed osteopenia and/or sclerosis and/or subchondral cysts, without any subchondral lucency (crescent sign)
MRI: geographic defect
Bone scan: increased uptake
clinical symptoms: pain and stiffness
Slide 10 - Stage III - X-ray: Crescent sign and eventual cortical collapse
MRI: same as plain radiograph
clinical symptoms: pain and stiffness +/- radiation to knee and limp
Slide 11 - Stage IV - X-ray: end-stage with evidence of secondary degenerative change
MRI: same as plain radiograph
clinical symptoms: pain and limp
Slide 12 - Stage IV
Slide 13 - image
Slide 14 - Steinberg staging of AVN
Slide 15 - Steinberg staging - STAGE 0:
- normal or non-diagnostic radiographs, MRI and bone scan of at risk hip (often contralateral hip involved, or patient has risk factors and hip pain)
STAGE I:
normal radiograph, abnormal bone scan and/or MRI
STAGE II:
- cystic and sclerotic radiographic changes
STAGE I AND II
A, mild: <15% head involvement as seen on radiograph or MRI
B, moderate: 15% to 30%
C, severe: >30%
Slide 16 - STAGE III:
- subchondral lucency or crescent sign
A, mild: subchondral collapse (crescent) beneath <15% of articular surface
B, moderate: crescent beneath 15% to 30%
C, severe: crescent beneath >30%
STAGE IV:
flattening of femoral head, with depression graded into
A, mild: <15% of surface has collapsed and depression is <2 mm
B, moderate: 15% to 30% collapsed or 2-4 mm depression
C, severe: >30% collapsed or >4 mm depression
Slide 17 - STAGE V:
- joint space narrowing with or without acetabular involvement
STAGE VI:
- advanced degenerative changes
Slide 18 - Association Research Circulation Osseous classification
Slide 19 - image
Slide 20 - Kerboul angle - Original classification was proposed on radiographs where he divided the necrotic region into small, medium and large regions:
Small - less than or equal to 160°
Medium - 161 to 199°
Large - 200 or more degrees.
Slide 21 - Modified Kerboul angle - based on MRI has much higher values as the MRI overestimates the necrotic region
Title: Understanding Giant Cell Tumor of Bone: A Comprehensive Overview
Introduction:
Giant Cell Tumor of Bone (GCTB) is a rare but potentially aggressive bone tumor that primarily affects young adults. While typically benign, it can be locally destructive and lead to significant morbidity if not managed appropriately. This presentation aims to provide a comprehensive understanding of GCTB, including its epidemiology, pathogenesis, clinical presentation, diagnostic modalities, treatment options, and prognosis.
Epidemiology:
GCTB accounts for approximately 5% of all primary bone tumors, with a peak incidence in the third and fourth decades of life. It shows a slight female predilection and commonly arises in the epiphyseal regions of long bones, particularly around the knee.
Pathogenesis:
The exact etiology of GCTB remains elusive, but it is thought to arise from mesenchymal stromal cells. Genetic alterations, including mutations in the H3F3A gene, have been implicated in its pathogenesis. Additionally, dysregulation of the RANK/RANKL/OPG pathway plays a crucial role in the development and progression of GCTB.
Clinical Presentation:
Patients with GCTB typically present with localized bone pain, swelling, and limited range of motion at the affected joint. Pathologic fractures may occur, especially in larger lesions. Rarely, patients may present with systemic symptoms such as fever and weight loss.
Diagnostic Modalities:
Diagnostic evaluation of GCTB includes imaging studies such as plain radiographs, which often show characteristic lytic lesions with well-defined margins and cortical thinning. Magnetic resonance imaging (MRI) provides detailed soft tissue evaluation and aids in surgical planning. Biopsy remains the gold standard for definitive diagnosis.
Treatment Options:
The management of GCTB is challenging and requires a multidisciplinary approach. Treatment options include curettage with or without adjuvant therapy (such as adjuvant bone cement, phenol, or cryotherapy), en bloc resection for aggressive or recurrent tumors, and denosumab therapy for unresectable or metastatic disease. Close surveillance is essential due to the risk of local recurrence.
Prognosis:
The prognosis of GCTB is generally favorable, with a low incidence of metastasis. However, local recurrence rates range from 10% to 50%, depending on the extent of surgical resection and the use of adjuvant therapy. Long-term follow-up is necessary to monitor for recurrence and late complications.
Conclusion:
In conclusion, Giant Cell Tumor of Bone poses a significant clinical challenge due to its potential for local recurrence and morbidity. Early diagnosis, appropriate staging, and a tailored treatment approach are crucial for optimizing patient outcomes. Continued research into the molecular mechanisms underlying GCTB pathogenesis and the development of targeted therapies are essential for improving treatment strategies and patient prognosis. Giant Cell Tumor of Bone (GCTB)
Fracture Prevention with Zoledronate in Older Women with OsteopeniaMushfiquzzaman Dipto
It is a journal presentation which was originally published by Ian R. Reid et al, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, NZ on October 1, 2018 at New England Journal of Medicine.
Chronic Recurrent Multifocal Osteomyelitis - a care report.pptxvinod naneria
Autoimmune chronic multifocal recurrent osteomyelitis , case report, Auto-inflammatory osteomyelitis in children, non-pyogenic osteomyelitis in both Tibia,
Conservative management of Lumbar disc prolapse.pptxvinod naneria
conservative management, non-surgical treatment of lumbar PID,
current concepts on Lumbar disc management, MRI correlation with neurological deficit in PID
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
1. Avascular Necrosis –
A practical approach
Girish Yeotikar
Arjun Wadhwani
Vinod Naneria
Choithram Hospital & Research Centre,
Indore, India
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. 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. Management protocol
• Early diagnosis
• Radiological evaluation
• Rule out other causes
• MRI
• Quantification
• Treatment algorithm
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. Radiology- sequential Changes
• Crescent Sign
• Osteoporosis
• Sclerosis
• Cystic changes
• Loss of spherical weight
bearing dome
• Partial collapse of head
• Secondary Osteoarthritis
7.
8. 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.
9. 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
10. MRI T1 image
• signal from ischemic
marrow
• Single band like area
of low signal intensity.
• 100% sensitivity
• 98% specificity
11. Double Line sign – T2 image
• A second high
signal intensity
seen within the line
seen on T1 images.
• Represent
hyper vascular
granulation tissue
12. 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.
16. 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
17. 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.
18. 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.
19. 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.
20. 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
21. 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
22. 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
25. Japanese Investigation Committee
Type 1 –
Line of
Demarcation
In relation to
Wt.bearing
Type 2-
Partial
Collapse
Type 3
Cyst
A- central
B peripheral
27. 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
28. 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
29. • 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
30. 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%
31. 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
32. 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.
33. 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
34. 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
35. 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
36. The basic question ?
• Head preservation – with collapse
• Varus osteotomy
• Valgus osteotomy
• Sugiako anterior rotation
osteotomy
37. 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
38. 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
39. 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
40. 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
41. 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.
42. Surgery - Core decompression + BG
• Bone graft options include
• structural cortical strut
• Cancellous bone graft
• Muscle-pedicle vascularized bone graft
• Free vascularized fibular graft.
43. 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.
44. 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.
45. 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
109. M. 50 M CRF
transplant left hip
1997
core decompression
3 years post op Oct.
2000
110. 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
112. 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
113. Osteotomy
• Several osteotomy procedures
have been tried with variable
success.
• Intertrochanteric osteotomies
have been performed in patients
with posttraumatic AVN.
114. 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.
120. 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
137. 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.
138. 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.
150. THR removed due to persistent pain cause?
AMP still working
151.
152. 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%)
153. 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
156. 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.
157. Carry Home Message –
Management Phylosophy
• Early diagnosis
• Early decompression
• Calcellous bone graft
• Bisphosphonate
• Osteotomy
• Replacement arthroplasty
158. • 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