5. Physical examination
Vital signs: BT 36.5 C PR 82 bpm BP 105/70mmHg RR 16/min
GA: A middle aged Thai male, good consciousness, well cooperated
HEENT: not pale conjunctivae, anicteric sclerae
Heart: normal s1s2, no murmur
Lungs: clear and equal breath sounds both lungs
Abdomen: soft, not tender
Neurological exam E4V5M6, pupils 3mm RTLBE
6. Orthopedic examination
Antalgic gait
Inspection no swelling, no ecchymosis
Full ROM both hips
Pain on passive and active motion
Anvil and rolling test - positive
Neurovascular intact
Physical examination
7.
8.
9. Diagnosis: Osteonecrosis of femoral head
both hips
(Ficat IV left hip, Ficat III right hip)
Management: Left Total hip arthroplasty
13. Definition
• Osteonecrosis / Avascular necrosis
• Osteonecrosis = Dead bone
• Avascular = loss of circulation due to potential causes
14. Anatomy
femoral head is at risk because its blood supply is retrograde and tenuous
enclosed by cartilage, giving restricted access to local blood vessels
16. • Corticosteroid
• 2 gm/month of prednisolone at least 3 months
• Alcohol
• <400 ml per week increase 3X
• >400 ml per week increase 9.8X
• Smoking relative risk 3.9
• Chronic inflammatory disease - SLE, RA
Etiology
17. Clinical presentations
• Asymptomatic (early)
• Groin pain on ambulation or weight bearing followed by
hip, thigh and buttock pain
• Hip pain on extreme ROM particularly when internal rotate
• Bilateral 40-80%
18. Diagnosis
• Symptoms
• Plain radiology
• AP view, Frog-leg lateral view
• Crescent sign best seen in frog leg position
• MRI
22. Ficat and Arlet Classification
Clinical Plain film MRI
Stage 0 No pain Normal Abnormal
Stage I Pain Normal +
Stage II +
Subchondral sclerosis and
cysts (IIA)
Crescent sign (IIB)
+
Stage III +
Cortical femoral head
collapsed
+
Stage IV +
Narrow joint space and
acetabulum
+
28. Management
• Pre-subchondral collpase
• Subchondral collapse
• Prophylaxis treatment for contralateral side
Left untreated..
Rate of collapse >85% in 2 years
in symptomatic patients
31. Operative treatment
Joint preserving procedure
• Core decompression
• Vascularized fibular
grafting
Prosthetic replacement
• Total hip arthroplasty
32. Core decompression
• Reduce intraosseus
pressure in the femoral
head
• Stimulate
neovascularization
• Only Pain relief,
NO advantage in prevention
of collapse
• Ficat and Arlet I, II
33. Vascularized fibular grafting
• Ficat stage II, III (10 year-
follow up)
• only 13 of 76 (17 percent)
were converted to THA
• Ficat arlet stage II, III
35. Prophylaxis treatment for
contralateral side
• Plain film on contralateral side
• MRI if normal radiography
• Leision <30% conservative and follow up
• Leision >30% operative treatment
• Severe pain - core decompression
36. Collapse?
Precollapse Postcollapse
To relieve pain
To prevent collase
Symptomatic
Conservative
treatment
Core decompression
Vascularized bone
grafting
THA
Intractable pain
Acetabular invovementAsymptomatic
Vascularized bone
grafting
Yes No
Editor's Notes
ข้างขวา collapse ของ femoral head
Subchondral Radiolucent line
No Joint space narrowing
ข้างซ้าย
Joint space narrowing
ลักษณธะของ 2 OA
Scleroric change
