avascular necrosis hip
DESCRIPTION
A devastating disease of hip, its causes, and management protocolTRANSCRIPT
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