slide presentation of a very promising surgical technic for a very elusive condition called avascular necrosis of femoral head.good clinical and surgical demo by dr mohamed ashraf,HOD, govt TD medical college ,alleppey,kerala, india

1. TENSOR FASCIA LATA
MUSCLE PEDICLE
GRAFT[TFL MPG] IN AVN hip
DR MOHAMED ASHRAF. Professor and head
drashraf369@gmail.com
DR Narayanan SK . Assistant professor
Govt TD medical college,alleppey,kerala,india

2. • From here to here painful
• active young man photo
• crippled wheelchaired man
PAINFUL
FROM HERE TO HERE

3. FROM HERE TO HERE TO HERE
CATASTROPHIC

4. • Presenting our long term
results of:
Modified TFL MPG
[tensor fascia lata
muscle pedicle graft]

5. AVASCULAR NECROSIS
• DEFINITION: temporary or permanent
loss of blood supply to bone resulting in
the death of bone cellular components –
marrow, fat and mineralized tissue
• Joint involvement: occurrence near a joint
can collapse leading to collapse of joint
surface and disabling arthritis

6. Pathophysiology
• Interruption of blood flow
• Early cell death
• Compartment syndrome
• Remodelling phase
• Final outcome  collapse of femoral
head

7. Etiology
• Idiopathic:
– Any bone
– Bilateral
– Most common FH
– M:F 8:1
– 30-60 years
• Post traumatic
• Secondary : alcoholism, steroids, radiation,
gout, hemoglobinopathies etc.

8. WHY FEMORAL HEAD?
• Most vulnerable: most
remote area of skeleton’s
vascular tree
• No collateral back up :
end arterioles supply
subchondral bone
• Heavy load : subject to
repeated body weight
loading

9. DIAGNOSIS OF AVN
• Radiographs : mineralized changes on x ray
lag 2-4 months behind insult, losing
precious time to treat
• Bone scan : sensitive but not anatomically
detailed
• MRI : gold standard
• Sensitive, specific, reliable basis for staging
by anatomic details

10. CLASSIFICATION
FICAT AND ARLET RADIOLOGIC STAGING (1980)

11. A R C O

12. TREATMENT OF AVN
• Preservation : sphericity of femoral head
• Decrease marrow pressure  prevents
further necrosis
• Increase vascularity
Stage one disease natural history : 70- 80% progress to FH
collapse without intervention

13. TREATMENT OF AVN
CONSERVATIVE
• Bed rest
• Constant traction
• Analgesics
• Limited weight
bearing
• Electrical stimulation
• Bisphosphonates
SURGICAL
• Core decompression/
with bone grafting
• Osteochondral graft
• Muscle pedicle graft
• Free vascularised bone
graft
– Osteotomy
• Joint reconstruction

14. CORE DECOMPRESSION
• relieves the pain for short
term
• but wont stop disease
progression.
• Not useful for
revascularisation of femoral
head.

15. OSTEOTOMY IN AVN
• Technically very
difficult
• Further decreases
vascularity of head
• Subsequent total hip
replacement difficult

16. Vascularised fibular or iliac
crest grafting
• Technically demanding
• single arteriovenouspedicle -torsion
,injury or thrombosis

17. THR IN YOUNG
• Analysis of twenty-seven studies
• 25 revealed a higher rate of early failure of
THR than age-matched patients with other
diagnoses
• Mont et all , JBJS Am Volume 77-A(3),March 1995,pp 459-474

18. • IMPORTANCE
BEST THING ON YOUR NECK IS
YOUR OWN HEAD

19. ADVANTAGES OF TENSOR
FASCIA LATA MUSCLE
PEDICLE GRAFT
• Simple procedure
• Reversal of pathology
• Healing of fracture if present
• Head preservation in young
• Doesn’t make THR difficult

20. • To evaluate functional outcome of
securely fixed muscle pedicle graft in
AVN
• To popularise the method of muscle
pedicle bone grafting fixed with CCS for
treatment of osteonecrosis of femoral
head.
AIM OF THE STUDY

21. MATERIAL AND METHODS
• Retrospective study
• Between 2007 and 2010
• Fifty patients of AVN stage I, II and III
treated with core decompression and
tensor fascia lata muscle pedicle graft
• minimum follow up period of two years.
• Maximum follow up period 5 years

22. • Ficat and Arlet staging was used
• Preoperative and postoperative Harris
Hip score and Visual analog scale were
used.

23. TFL MPG Surgical technique
Standard Watson-Jones
approach

24. GRAFT MOBILISATION
• Middle third of TFL with an
overlying piece of fascial
sleeve + 2.5cm length and
height of the iliac graft
• Bone part predrilled and
tapped
• No stretching of the muscle
pedicle

25. • Grafting-Window of about 1.5
x 1.5 (neck close to the head)
• All necrotic and hard materials
were curetted out.
• Multiple drill holes are made
through the window to the head
to facilitate the revascularization
• Muscle-pedicle bone graft fixed
inside the slot
• Fixed with a canulated screw

26. position skin incision exposing anterolateral
aspect of femur head
A 1cm to 1.5cm
window made at head
neck junction
Curettage of necrotic
bone
Core decompression

27. extending skin
incision for harvesting
TFL MPG
Predrilling and
tapping for cannulated
screw
A 30 mm long 4mm
cannulated cancellous
screw used
Inspected for secure
fixation
closure

28. Dissected model

29. POST-OP PROTOCOL
• Sutures removed on 10th day
• Static exercises started as soon as the pain is
relieved
• ROM exercises after 2 weeks
• NON-weight bearing for 6 weeks
• Partial weight bearing up to 12 weeks
• Full weight bearing after 12 weeks

30. FOLLOW UP
• Clinical and Biologic improvement in
response to the treatment
• Clinical improvement —relates to pain relief
and function restoration and delay of total
joint arthroplasty
• Biologic improvement —decreasing lesion size
or increasing bone density or blood flow

31. RESULTS
• All fifty patients had pain relief and
improvement in range of movements at
the end of 10-12 weeks.
• Eight patients had residual low intensity
pain for a period of 24 weeks and 10
patients had painless limp for a period of
16-18 weeks.
• Eight patients with stage III had
improvement in flexion beyond 90°- 100°
till the last follow up of five years.

32. • Radiographs taken in the post operative
period showed good position of the graft
with canulated cancellous screw in situ.
• Subsequent radiographs at 4, 6, 12 and
24 months showed good union in forty
four patients.

33. six hips from stage III progressed to
further collapse , but without any
progression to arthrosis .
• Two patients had superficial infection at
the operative site and the wound
responded promptly.
• One patient developed screw loosening by
accidental fall but graft incorporated

34. • no other complications occurred in any
other patients.
• At the final follow up period of 2 years,
Haris hip score improved. 82% of
patients had improvement in Haris Hip
score of more than 22 points.

35. CONCLUSION
• TFL MPG gives predictably good results in
avn before major collapse and arthrosis
• TFL MPG is the biological option since it
revascularise and reverses the pathology
• Procedure can be performed by general
orthopaedician exposed to hip surgery
• Early collapse is not a contraindication
since cartilage remains less affected

39. Message is clear
this simple but excellent method
must be the procedure of choice
for AVN without major collapse
and arthrosis

41. MBBS [GMC CALICUT]
D ORTHO [GMCTRIVANDRUM]
MS ORTHO [MMC MADRAS]
DNB,MNAMS [NEW DELHI]
drashraf369@gmail.com