avascular necrosis hip

Avascular Necrosis –Femoral Head

A practical approach

Vinod NaneriaGirish Yeotikar

Arjun Wadhwani

- 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.

Management protocol• Early diagnosis

• Radiological evaluation

• Rule out other causes

• MRI

• Quantification

• Treatment algorithm

Early Diagnosis – suspicion ?

• High degree of suspicion in a patient C/o anterior HIP pain, Especially with:-

H/o Cortisone – Skin, Eye, Liver, Asthma,

RA, Weight gain, PID –

H/o Alcohol abuse

Traumatic - # N/F, D/ of F, # Acetabulum

Hemoglobinopathy – Sickle / Myelo-infiltrating

Other causes

• Pregnancy

• Renal Diseases

• Radiation

• Gout / Collagen disorder

• Gaucher’disease

• Dysbarism

• Idiopathic

Radiology- sequential Changes

• Crescent Sign

• Osteoporosis

• Sclerosis

• Cystic changes

• Loss of spherical weight bearing dome

• Partial collapse of head

• Secondary Osteoarthritis

Bilateral Cystic changes With patchy sclerosis

The second step - MRI

• 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 etc.

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

MRI T1 image

signal from ischemic marrow

• Single band like area of low signal intensity.

• 100% sensitivity

• 98% specificity

Double Line sign – T2 image

• A second high signal intensity seen within the line seen on T1 images.

• Represent hyper vascular granulation tissue

Early

Late

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

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

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

Association Research Circulation Osseous quantification

Relationship with weight bearing dome

Japanese Investigation Committee

Type 1 –Line of DemarcationIn relation toWt.bearing

Type 2-Partial Collapse

Type 3CystA- centralB peripheral

Kerboul:- combined necrotic angle – AP LAT

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

The basic question ?

• Head preservation – with collapse

• Varus osteotomy• Valgus osteotomy• Sugiako anterior rotation

osteotomy

The basic question ?

• Head sacrifice –• Surface replacement

(Birmingham's)• Non – cemented THR• Cemented THR• Cemented Bipolar• AMP• Girdle Stone – Excision

arthroplasty

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

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

• 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

Stulberg et al CORR 186: 137-153, 1991 Randomised prospective study, 55 hips in 36 pts

Good ResultsCD No Tx

• Stage 1 70% 20%

• Stage 2 71% 0%

• Stage 3 73% 10%

Kaplan-Meier survival curvesCore 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

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.

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 areaBetter the result of Osteotomy

Pre-Collapse Hips

• Check extent of lesionIf 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

Pre-Collapse Hips

Location of lesionType A (medial) - observation with periodic followup

i. Type B,C - Core decompression

Other considerations:

i. Diagnosis: SLE do worse

ii. Continued Steroid: Do Worse

iii. Age and compliance

Guide-lines for management

Post-Collapse Hips1.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

Post collapse

Late-Collapse - symptomatic treatment till resurfacing or THR necessary

Guide-lines for management

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

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

Summaries of cases with head preservation by free fibula grafting

Firoza 35 f post delivery 1992

Firoza 35 f post delivery pelvis July 2000

Kanti 35 f post delivery AVN 1988

Kanti 35 f post delivery AVN July 2000

Upadhyay rt hip

Upadhyay

Upadhayay after one year

Bharat post posterior dislocation

Bharat after one year

Jakir post cortisone cystic lesion

Jakir after fibula grafting

Rajendra

Fibula grafting

Romi varma

MRI-Romi

After 6 months

After one year

Shyamlal

Bilateral grafting

Ashok 2001

Pre OP

Post OP

Chandu Rane 1 / 2003

Chandu Rane 12 / 2003

Chandu

Kamal 30 m

Deep chand 3 yrs PO

Kamal Kishor 35 M AVN 1983

Osteotomy

19891983

Kamal Kishor 35 M AVN

Kamal Kishor Aug.2000

Rekha 30 f post delivery left hip 1985

Rekha 30 f post delivery left hip 1989

Manoj- 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 side2005 – came for removal of implants

19972000

2005

Osteotomy

Archna 22 f CRF transplanted sept 2000

Archna 22 f CRF transplanted sept 2000 left hip free fibula grafting

Archna 22 f CRF transplanted Sept 2000 rt.hip AM Prosthesis

After 2 years

Rajesh 28 M CRF Transplant rt.hip AVN

Rajesh 28 M CRF Transplant rt.hip AVN core decompression FU 2/12 Nov 2000

Core decompression failed

Modi 50 M CRF transplant left hip 1997

Modi 50 M CRF transplant left hip 1997

Modi 50 M CRF transplant left hip 1997

Modi 50 M CRF transplant left hip core decompression 3 years post op oct 2000

Replacement - options

• Hemiarthroplasty

• Bipolar arthroplasty

• Surface replacement arthroplasty.

• Newer material for THR ceramic on ceramic

• Non cemented / cemented THR

Krishna

Krishna 35 f

THR • Patient aged 50 & more

• Advance osteoarthritis and reduction of joint space.

• Radiation necrosis

• Result less than Ideal. – necrotic bone

• Poor in Sickle cell disease.

• Cementless are superior over cemented THR

Malakar post alcohol AVN Bil THR 1991

Malakar post alcohol AVN Bil THR 9 year postop Nov 2000

Bhumika 19 yrs

Bhumika – Non Cemented THR

Thank You

The End Of AVN Story