The document presents a study on the modified tensor fascia lata muscle pedicle graft (TFL MPG) for treating avascular necrosis (AVN) of the hip. It outlines the procedure's efficacy, revealing that all fifty patients experienced pain relief and improved mobility after treatment. The TFL MPG is highlighted as a viable biological option to reverse the pathology of AVN before significant joint collapse occurs.

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