AVN of Femur

1. CASE CONFERENCE
Ext.เวชพิสิทธิ์ พนาวร

2. PATIENT PROFILE
• ผู้ป่วยชายไทยอายุ 75 ปี
• Chief complaint: ปวดข้อสะโพก 2 mth PTA
• Present illness: ปวดข้อสะโพก บริเวณขาหนีบร้าวมาที่ข้อเข่า 2 mth PTA ไม่มีปวดหลัง ไม่มีชา ไม่อ่อนแรง เดินได้แต่ผิดปกติ
เดินแล้วไม่มีปวดมากขึ้น โดยมีอาการปวดตลอดเวลา ไม่มีทาท่าทางใดแล้วดีขึ้น แต่จะมีอาการปวดมากขึ้นตอนยกขาเข้ามาด้านใน ไม่มี
ประวัติtraumaมาก่อน
• Past illness : Underlying COPD, Gout
• Personal history : Hx of smoking 40 pack-year,No Hx of alcohol drinking,No Hx
bleeding disorder

3. PHYSICAL EXAMINATION
• Vital signs: BP 139/75, PR 100 bpm, T37.5c, RR20
• GA: good conscious, well co-operated
• HEENT: Not pale, No jaundice
• CVS: Normal S1S2, No murmur, symmetrical pulses on all extremities, No cyanosis
• Lung: clear, normal equal BS, No adventitious sound, No dullness on percussion
• Abdomen: Soft, Not tender, No rebound tenderness, No sign of chronic liver disease

4. • Orthopedics examination: Lt. Hip -> Limit ROM in internal rotation, Not tender at
hip, Normo reflexia, Muscle power grade V all extremities

5. LABORATORY
CBC
• WBC 17,000 /uL
• HGB 12.2 g/dL
• HCT 36.7%
• MCV 98
• RDW 14.3
• PLT 206,000
• N 89.7%, L3.3%, M5.7%, E0.4%, B0.9%

6. LABORATORY 2
• Sodium 138.1
• Potassium 3.61
• Chloride 101.4
• Co2 24
• BUN 13
• Cr 1.41
• CRP 125
• ESR 57(H)
• Anti-HIV (-)

7. FILM: BOTH HIP AP

8. MANAGEMENT
• Total hip arthroplasty

9. AVASCULAR NECROSIS
• Osteonecrosis of femoral head
• Most common incidence: 30-50 years
• Pathogenesis: ยังไม่ทราบแน่ชัด
• Risk factors: Trauma, Corticosteroid use, Excessive alcohol consumption,
Coagulation disorder, Hemoglobinopathies, Dysbaric phenomena, Autoimmune
diseases, Storage diseases, Smoking, Hyperlipidemia

10. PATHOGENIC MECHANISM OF AVN
• Ischemia 1. Vascular disruption
2.Vascular compression or constriction
3. Intravascular occlusion
• Direct cellular toxicity
• Altered differentiation of mesenchymal stem cells

11. CLINICAL PRESENTATION
• Groin pain
• Limit hip internal rotation
• Antalgic gait

12. HOW TO DIAGNOSE AVN OF
FEMORAL HEAD?
• Radiograph (X-ray or MRI)
-Ficet and Arlet classification system

15. CRESCENT SIGN

18. TREATMENT
• Non surgical treatment
1.Non-weight bearing therapy : For small and asymptomatic lesion
2.Biophysical modalities: ESWT(Extracorporeal shock waves therapy)
HBO(Hyperbaric )
3.Pharmacotherapy : Enoxaparin, Bisphosphonates

19. SURGICAL TREATMENT
• Femoral head-preserving procedure
1.Core decompression
2.Core decompression with nonvascularized bone grafting
3.Vascularized bone grafting
4.Concentrated stem cell
5.Biologic adjuncts
6.Tantalum rods
7.Rotational osteotomy

20. SURGICAL TREATMENT(CONT.)
• Hip arthroplasty
1.Total hip arthroplasty
2.Resurfacing artroplasty

21. CONCLUSION
1. Symptomatic osteonecrosis + Small lesions + Pre-collape stage
-> Femoral head-sparing procedure
2. Young people + symptomatic osteonecrosis + large lesions + Pre-collapse
stage -> Femoral head-sparing procedure
3. Old people + symptomatic osteonecrosis + large lesions + Pre-collapse
stage ->Total hip arthroplasty
4. Symptomatic osteonecrosis + Post-collapse stage-> Total hip arthroplasty