Avascular necrosis femoral head by DR RAJAT MALOT (MS,DNB,Fellowship paediatric orthopaedics)
1. AVASCULAR NECROSIS
FEMORAL HEAD
By :
Dr. Rajat Malot
Assistant Professor
SMS Medical college
Jaipur
2. How to Approach a patient with
Hip Pain
• Detailed History :
Trauma ,Drug intake,Any other joint
involvement,Constitutional symptoms,Any
metabolic or endrocrine disorder
• Pain : Exact site, mode of onset,Radiation
• Age
• Gait : Antalgic /Trendelenberg
3. Anterior Hip pain or Lateral pain or Posterior hip pain
Groin pain Trochanteric pain
Rule out: hip Rule out: hip Rule out: sciatic
fracture, septic joint, fracture, bone tumor, nerve irritation
and avascular referred pain from ,sacroiliitis due to
necrosis lumbar disc spondyloarthropathy,
herniation lumbardisc or facet
disease
Other causes:OA, Other causes:
RA, trochanteric
iliopectineal bursitis bursitis,OA, radiating Other causes:muscle
from strain
lumbar disc or facet
disease
4. CLINICAL PRESENTATION
No distinguishing Clinical Features/ High index of
suspicion
Asymptomatic Pain gradual & insidious in nature
Range Of Motion (ROM) ; patient may walk with a limp
Radiographic findings may appear after a delay of
several months to years following the onset of symptoms
5. Characteristics Of Pain
Focal over the groin / hip or it may radiate to the buttocks,
anteromedial thigh or knee
Induced mechanically by standing & walking & may be eased
by rest
May be very intense, throbbing, deep & often intermittent
Worsened by coughing & at night
40% of patients have night pain asso. with morning stiffness
A Click may be heard when the patient rises from a sitting
position or on external rotation of an abducted hip
6. Range Of Motion
ROM may be diminished, especially after collapse of the
femoral head
ROM may be limited, especially in flexion, abduction & internal
rotation
Gait :- Patients may walk with a limp.
The Trendelenburg sign may be Positive
To be diagnosed at an early stage, high index of suspicion,
especially true with U/L involvement because of the high risk of
the dev. of AVN in the C/L Hip
7. BLOOD SUPPLY OF FEMORAL HEAD
The principal sources are the Lateral Epiphyseal Vessels
(LEVs).
LEVs Posterior Superior Retinacular Vessels (PSVs)
Medial Femoral Circumflex Artery Profunda-
Femoris Artery.
LEV supplies lateral and central thirds of the femoral head
When patent, the Artery of Ligamentum Teres(ALT) supplies
medial third of the femoral head.
Branches of LEVs & ALT anastomose at the junction of central
& medial 1/3 of the femoral head
9. Blood Supply in Paediatric Age Gp.
Till 4-7 years of age, the vascular anatomy in a
age
transitional stage of development.
The ALT does not penetrate the epiphysis of the femoral
head until 9 or 10 years of age.
The Medial Circumflex Artery (br.of Profunda Femoris
Artery), penetrates into the femoral proximal metaphysis
but is prevented from passing into the femoral epiphysis
by the growth plate.
The blood supply to the femoral head is especially
vulnerable during this time.
10. AVN HISTORY
Konig (1888) => first described the condition coined the
term Osteochondritis Dissecans
Haenish (1925) => first case of idiopathic ischemic
necrosis of the femoral head in an adult
Arterial Occlusion (1940) was postulated as the cause of
the necrosis.
Pietrograndi (1957) => AVN d/t Steroid therapy
11. AVASCULAR NECROSIS
Misnomer; Basically it is Osteonecrosis (dead bone)
Also c/a Osteochondritis Dissecans / Chandler’s Disease
in Young Adults
60% => B/L
One of the most challenging problems faced by orthopaedic
surgeons.
Annual Incidence in US 15,000-20,000
Estimated Burden => 10% of total THR’s d/t AVN (50,000)
25% of total expenditure on AVN (1 billion $)
12. AVASCULAR NECROSIS
M/c affects => Femoral Head
M/c site => Anterolateral aspect (Being principal Wt.
bearing portion)
Incidence d/t Steroid usage & Trauma
AVN only occurs in FATTY MARROW, which contains
MARROW
a Sparse vascular supply. In contrast to Hematopoietic
supply
marrow which has a rich blood supply
13. Does Elderly Persons are at
increased risk for AVN?????
AVN
NO……………….
Fat cells become smaller in elderly persons. The space between fat cells fills
with a loose reticulum and mucoid fluid, which are resistant to AVN. This
condition is termed Gelatinous marrow .
Even in the presence of increased intramedullary pressure, interstitial fluid is
able to escape into the blood vessels, leaving the spaces free to absorb
additional fluid.
14. ETIOLOGY
Intravascular Extravascular
Extraosseous Intraosseous
vascular factor factors
I. Arterial factors
Capsular factors
Intraosseous
vascular factors
I. Arterial factors
II. Venous factors
15. Extraosseous Vascular Factors
Arterial Factors
Most important
Femoral Head blood supply is an End-Organ System
with poor collateral development
Trauma to the hip may l/t contusion or mechanical
interruption to the Lateral Retinacular Vessels (main
blood supply of the femoral head & neck)
16. Intraosseous Vascular Factors
Arterial Factors
Circulating microemboli that block the
microcirculation of the femoral head
In Conditions like-
6. Fat emboli (hyperlipidemia associated with alcoholism)
7. steroid therapy
8. SCD
9. nitrogen bubbles in decompression sickness
17. Intraosseous Vascular Factors
Venous Factors
Enlargement of intramedullary fat cells or fat-loading
osteocytes causes the cells to expand; this may be the
most significant factor l/t obstruction of venous drainage
Reducing venous outflow & causing stasis
S/i Caisson disease & SCD
18. Extravascular Factors
Intraosseous Factors
Ficat et al demonstrated increased bone marrow
pressure in the femoral necks of a large number
of patients with avascular necrosis of the femoral
head (AVN).
Steroid Alcohol & Steroid
Hypertrophy of Fat cells
Gaucher cells & Inflammatory cells
Encroach on intraosseous capillaries
Direct toxic metabolic
Intramedullary circulation effect on osteogenic cells
Compartment syndrome
20. SEQUELAE OF AVN
Minimal AVN More Severe AVN
Avascular area is small Once AVN develops, repair
& is not adjacent to an Begins at the interface b/w
articular surface. viable bone & necrotic bone
Patient may be
Asymptomatic
Ineffective Resorption of
Healing may occur dead bone within the necrotic
spontaneously or the focus is the rule.
disease may remain Mixed sclerotic and cystic
undetected appearance on radiographs.
21. SEQUELAE OF AVN
MECHANICAL FAILURE
Non-healing Micro# in Subchondral region
Collapse of the Vicious Cycle Diffuse Subchondral #
Articular Cartilage X-Ray :- Crescent
Progressive Wt. Bearing
Degenerative joint disease (DJD) & Joint Dissolution
24. CAUSES
Steroid (35-40%)
6 mechanisms
• Fat Emboli from the liver => Occlusion of Small Vessels
• Steroid Intramedullary Fat Cells Size without an equivalent
compensatory loss of trabecular & cortical bone => Intraosseous
pressure
• Fat Emboli Hydrolysis FFAs Toxic to vascular endo.
Intravascular Coagulation
• Synthesis of Polyclonal Antithyroid Hormone Receptor Alpha-Ab
(-)
Angiogenesis Proteolytic Activity
10.A direct toxic effect occursSteroid Induced Blood Flow
on osteogenic cells
11.Hematopoietic Marrow Fatty Marrow
> 20 mg & 6 Wks => Risk
25. Investigations
MRI SPECT CT Scan Plain X-Ray
Most Sensitive Reflects Vascular Integrity
Unable to detect disease of
1.5-T magnet Avascular Focus may be stage 0 or 1
88% sensitivity demonstrated Early in
100% specificity Disease (MRI Contrast) Helpful in assessing flattening
of the Femoral Head & asso.
94% accuracy 85% sensitivity Degen. changes
(Beltran et al) (Collier)
For Extent of Involvement
Indispensable for Triple-Head High- e.g. Subchondral Lucencies
Accurate Staging resolution SPECT & Sclerosis during Reparative stage
of AVN because Sensitivity 97%
images clearly depict (Lee et al) Enables detection of subchondral or
12. Size of the lesion cancellous # & collapse
13. Gross estimates of
26. Radiology- sequential
Changes
• Crescent Sign
• Osteoporosis
• Sclerosis
• Cystic changes
• Loss of spherical weight
bearing dome
• Partial collapse of head
• Secondary Osteoarthritis
27.
28.
29. MRI Findings
Classic Findings:- look for focal lesion in the
anterosuperior portion of femoral head that is well
demarcated but is inhomogeneous
T1 images => low signal intensity
T2 images => double line sign => classic sign of AVN,
made up of 2 concentric low and high signal bands
high-signal-intensity line may represent hypervascular
granulation tissue
30. MRI T1
image
∀ ↓ signal from
ischemic marrow
• Single band like
area of low signal
intensity.
• 100% sensitivity
• 98% specificity
31. Double Line sign – T2
image
• A second high
signal intensity
seen within the
line seen on T1
images.
• Represent hyper
vascular
granulation
tissue
35. Prominent & Thickened
but Normal Trabeculae
ASTERISK SIGN
Axial CT: Patient without AVN of the Femoral Head
36.
37.
38.
39. TRANSIENT OSTEOPOROSIS OF THE HIP
(TOH)
D/D:-
No findings of bone infarction or repair, which are the hallmarks of
osteonecrosis
The pathologic picture is primarily one of marrow edema, hence also
referred to as Bone marrow edema syndrome (BMES)
Clinically, pain is usually more sudden, severe
in females esp.during 3rd trimester of pregnancy
Dx can be made readily based on MRI in most cases
TOH is usually self-limited.T/t is protected weight bearing to prevent #.
Infrequently, core decompression may be indicated if a patient has an
inordinate amount of pain or if the diagnosis is in doubt.
A diffuse low signal intensity in the T1-weighted image and a high intensity
in the T2-weighted image
40.
41. CLASSIFICATION & STAGING
• In the 1960s, Arlet & Ficat in France
described a 3-part staging system & in the
1970s a 4th stage was added
Paul FICAT
This form is perhaps the one most widely used now, despite the
fact that a stage 0 & a transitional stage were added later
42. Paul FICAT
1917-1986
FICAT’s scientific works spanned a wide range of topics from
ligament instability to osteoarthrosis & from chondromalacia
patellae to AVN
To each area he brought not only the perception of the clinician
but also the ability to see with the eyes of the physiologist, the
microscopist & even the electron microscopist
He was one of the few orthopedic clinicians with the ability to
“see” problems at the cellular and subcellular level
43. Ficat & Arlet Classification
t Stages of Bone Necrosis
Stage Clinical Features Radiographs
0 Preclinical 0 0
1 Preradiographic + 0
2 Precollapse + Diffuse Porosis,
Sclerosis, Cysts
3 Early Collapse ++ Crescent Sign
Certain Sequestrum,
Joint Space Normal
4 Osteoarthritis +++ Flattened Contour
Decreased Joint Space
Collapse of Head
44. A major disadvantage was that it didn’t include any
measurement of lesion size or articular surface
involvement..
45. Radiographic Staging
(Marcus et al 1973)
Stage 1 : Asymptomatic, mottled increased density of
femoral head
Stage 2 : Asymptomatic , area of necrosis demarcated by a
rim of increased density
Stage 3 : Intermittent pains, Crescent sign in frog lateral
view
Stage 4 : Painful limb & flattening of femoral head
Stage 5 : Symptoms & signs of degenerative arthritis
Stage 6 : Severe degenerative arthritis
46. Steinberg et al (1995) Modified
Ficat & Arlet Classification
Stage 0 – 3 :- Same as Ficat Arlet
Stage 4 :- Flattening of femoral head
Stage 5 :- Joint narrowing with or without acetabular
involvement
Stage 6 :- Advanced degenerative changes
These stages were further divided into
Mild, Moderate & Severe
47. 1974, Kerboul et al noted that the results of osteotomies
performed for osteonecrosis depended on both the location &
the extent of the lesion
This latter was expressed in degrees after measuring the arc of
the articular surface involved as seen on both AP and lateral
radiographs of the femoral head.
Similar observations were reported by Wagner and Zeiler ,
Sugioka et al. and Koo and Kim
49. University Of Pennsylvania
Classification of Osteonecrosis
0 Normal or nondiagnostic x-ray, bone scan, and MRI
I Normal x-ray; abnormal bone scan and/or MRI
A. Mild (15% of femoral head affected)
B. Moderate (15%–30%)
C. Severe (30%)
II “Cystic” and sclerotic changes in femoral head
A. Mild (15% of femoral head affected)
B. Moderate (15%–30%)
C. Severe (30%)
III Subchondral collapse (‘Crescent Sign’) without
flattening
A. Mild (15% of articular surface)
B. Moderate (15%–30%)
C. Severe (30%)
50. University Of Pennsylvania
Classification of Osteonecrosis
IV Flattening of femoral head
A. Mild (15% of surface and 2 mm depression)
B. Moderate (15%–30% of surface or 2–4 mm depression)
C. Severe (30% of surface or 4 mm depression)
V Joint narrowing and/or acetabular changes
A. Mild (Average of femoral head involvement as determined in stage IV &
estimated acetabular involvement)
B. Moderate (Average of femoral head involvement as determined in stage
IV & estimated acetabular involvement)
C. Severe (Average of femoral head involvement as determined in stage IV
& estimated acetabular involvement)
VI Advanced degenerative changes
From Steinberg ME, Brighton CT, Corces A. Osteonecrosis of the femoral head:
Results of core decompression and grafting with electrical stimulation
51. 1991, The Committee on Nomenclature & Staging of the
Association Research Circulation Osseous (ARCO) endorsed
the staging system developed at the University of
Pennsylvania in the early 1980s
1992, location of the lesion, as described in the Japanese
system , was added
1993, stages III & IV were combined, as were stages V & VI
52.
53. Mitchell’s MRI Staging
Class T1 T2 Definition
A Bright Intermediate Fat signal
B Bright Bright Blood signal
C Intermediate Bright Fluid or edema
signal
D Dark Dark Fibrosis signal
54. Criteria For Diagnosis
(Current Concept JBJS Mont & Hungerford)
Specific Criteria Non specific criteria
Collapse of femoral head Collapse of femoral head with
narrowing of joint space
Subchondral radiolucent line
Mottled ,cystic & sclerotic pattern in
Anterolateral sequestrum head
Bone scan showing a photopenic MRI showing changes in bone
region surronded by area of
increased density marrow
Double band on T2-weighted Painful movements of hip with
image normal X ray
Bone biopsy showing empty H/O of alcohol & steroid intake
lacunae involving multiple adjacent
trabeculae Non specific but abnormal biopsy ,
edema /fibrois
55. AIM OF TREATMENT
Preserve rather than Replacing Femoral Head &
Cartilage
Early Intervention has favorable impact on the
disease prognosis irrespective of T/t modality
used
56. Medical Management
Indications:-
Small, Asymptomatic lesions
Lesion is so advanced that prophylactic measures
would be of little value
When Sx is contraindicated or declined
Buying time until arthroplasty is needed
57. PROTECTED WEIGHT BEARING
Protect the involved area from excessive stress by using some form of limited
weight bearing. Canes or even crutches are frequently prescribed
Don’t alter the natural course of the disorder
INDICATIONS:-
Alternative to surgical management
Small, Asymptomatic lesions
low weight bearing area, such as the medial aspect of the femoral head
Poor medical condition
Following certain types of surgical procedures, such as core
decompression, grafting, and osteotomies (used as an adjunct)
Most important role :relatively advanced stages of osteonecrosis.
Cane or Crutches can diminish symptoms and improve function considerably
until such time as a reconstructive procedure is indicated
58. Glueck & colleagues => Incidence of
osteonecrosis in association with certain
Coagulopathies & Hyperlipidmias
60. Motomura et al => Incidence of Steroid-induced
osteonecrosis in rabbits using a combination of
Warfarin & Probucol (Lipid Lowering Agents)
61. ENAXOPARIN adminstered for 12 weeks was
found to prevent radiographic Progression of
Stage 1 and Stage 2 idiopathic osteonecrosis
of the femoral head at 2 year follow up
62. Gauthier => 95%-100% of transplant patients
who were treated with Calcium Channel
Blockers experienced complete relief of Bone
Pain Syndrome
63. I.V. ILIOPROST, a Vasoactive Prostacyclin
analogue showed significant improvements in
patients with Bone Marrow Edema Syndrome &
Osteonecrosis
64. Oral Nifedipine => Relief of bone pain reported
in a small series of patients with Osteonecrosis
65. Alendronate :- In a prospective study of 100 hips with
osteonecrosis, Agarwal et al reported that l/t significant
improvement in Pain & Disability scores
Marrow edema improved on MRI & plain films were unchanged
or progressed one grade
In a prospective randomized study of 40 patients with stage II
or III osteonecrosis & minimum 2-year follow-up, only 2 of 29
patients taking alendronate experienced collapse of the femoral
head, whereas 19 of 25 heads in the control group collapsed
67. Puerarin :- An extract of the kudzu vine , is purported to
Cholesterol, Platelet Aggregation & cause Vasodilation.
In a study of Alcohol-induced Osteonecrosis in mice, puerarin
was reported to lower serum cholesterol & to prevent the
changes of osteonecrosis in femoral heads.
No data on the use of puerarin for osteonecrosis in humans
are available
68. Electric, Electromagnetic & Acoustic T/t
Pulsed Electromagnetic Field stimulation, is
reported to be useful for treatment of
osteonecrosis in 4 reports.
Mechanisms Of Action:-
5. Local control of inflammation
7. Enhances repair activity & healing process by
stimulating neovascularisation & new bone
formation.
69. Radiographic progression in Ficat stage II . Hips treated with core decompression
(CD) plus pulsed electromagnet fields (PEMF) exhibit 33% less radiographic
progression than hips treated with CD alone (P 0.04)
70. Extracorporeal Shockwave Therapy
There are only 2 papers in Pubmed
The only study is by Wang et al who compared the
results of such therapy in 23 patients (29 hips) with the
results in a group treated with non-vascularized fibular
grafting
At a mean of 25 months, 79% of the shock-wave group
had improved Harris Hip Scores compared with 29% of
the group treated with non-vascularized fibular grafting
71. Hyperbaric oxygen (HBO)
HBO improves oxygenation, reduces oedema & induces
angioneogenesis, a reduction in intra osseous pressure
& improvement in microcirculation
Reis et al, 24 involving 16 hips in 12 patients, all with
Steinberg Stage 1 disease, gave each patient 100
consecutive days of HBO, which involved breathing
100% oxygen via a maskat 2-2.4 atmospheres pressure
for 90 minutes
They reported that 13 of the 16 femoral heads
subsequently appeared normal on MRI after this T/t
72. Bone Marrow Injections
Supplemented with Core Decompression
Principle:-
The small no. of progenitor cells in the proximal extremity
of the femur with osteonecrosis of the femoral head
causes insufficient creeping substitution after
osteonecrosis
Red Bone Marrow Graft contains Osteogenic
Precursors,which repopulate the osteonecrotic bone
73. Bone Marrow Injections
Technique
Usual site => Anterior Iliac Crest
A beveled metal trocar of 6 to 8 cm
length & a bore of 1.5 mm is
pushed deep into the cancellous
bone
Marrow is aspirated with A 10 ml
syringe(flushed with heparin)
Aspirates pooled in plastic bags
containing an anticoagulant
solution
Filtered to remove fat aggregates &
clots
Trocar
74. Bone Marrow Injections
Current Indications:-
The best indications are hips with osteonecrosis &
without collapse
In some patients who had Steinberg stage III
(subchondral crescent, no collapse), successful
outcomes (no further surgery) have been obtained
between 5 and 10 years. Therefore, in selected
patients, even more advanced disease can be
considered for core decompression
76. Surgical procedures
Joint Preserving Joint Replacing
Core
Total Hip
Decompression
Arthroplasty
Various
Hip Resurfacing
Nonvascularized &
Procedures
Vascularized Bone
Grafting Procedures
Osteotomy
Procedures
77. Core Decompression
Core decompression was
“discovered” by Paul Ficat
& Jacques Arlet in the
1960s
Incidental discovery
78. Core Decompression
Indications:-
Core decompression is effective for symptomatic relief in
nearly all stages in all patients who present with a painful
hip secondary to ON d/t of intramedullary pressure done
by it
Transient symptomatic relief in an advanced stage & in
already collapsing or when collapse is impending
It is Most Effective in Stage I & II lesions that are size A
(15% of head affected) & B (15%–30% of head affected)
The larger the lesion, the less likely the patient is to have a
successful outcome.
79. Core Decompression
Standard Technique & its Variations:-
Ficat & Arlet proposed creating an 8 to 10 mm dia core
track & this became a “standard”
Recently some authors have suggested that the same effect
of standard core can be achieved by producing Multiple
Smaller Core Tracks of 3-mm dia range. This can be done
percutaneously & theoretically # risk & shortens the
operative time & morbidity
Steinberg et al proposed making Smaller Angled Core
Tracks into the Necrotic Segment from the Central Core
Canal
80. Core Decompression
Postoperative Management
The lateral cortical window produces a stress riser in the
proximal femur So Protect the patient from
unprotected weightbearing for the first 6 weeks
Reported incidence of # with core decompression is <1%
& has almost always been associated with either a fall or
failure to use protective devices (crutches or a walker) in
the first 6 weeks
81. Bone Grafting Procedures
Bone grafting procedures are a group of joint preserving
techniques that involve the removal of the diseased femoral
head segment, f/b its replacement with 1or more of a variety of
bone graft options
These are most valuable in treating patients with Stage I & II
disease
82. Bone Grafting Procedures
Techniques:-
Grafting Through Lateral Core Track
Grafting Through Femoral Neck Window
Grafting Through Articular Surface Window
84. Grafting Through Lateral Core Track
Advantages:-
Simple technique
Minimal Invasiveness
Avoidance of surgical dislocation of the hip
Low Complication Rate
Can be performed bilaterally under one anesthetic
Disadvantages:-
Inability to directly visualize the joint surfaces
Inexact nature of removing diseased bone & replacing it
with bone graft under fluoroscopic guidance
Risk of postoperative #
85. Grafting Through Femoral Neck Window
Watson-Jones or Smith-Peterson approach
is used
A window is created to expose the anterior
femoral neck, at the level of the junction of
the femoral head & neck
When Combined with a Bone Grafting
procedure,refered as the “light bulb”
procedure.
Advantage is the improved access to the
necrotic femoral head segment & the
avoidance of direct iatrogenic cartilage
damage
Disadvantage is the creation of a cortical
defect in the femoral neck, which raises the
risk of fracture
86. Grafting Through Articular SurfaceWindow
The 3rd method of accessing the necrotic segment of the femoral head is
known as the “Trapdoor” approach
With this method, the hip is surgically dislocated using a technique aimed at
preserving the blood supply to the femoral head & neck
Once exposed, a “trapdoor” window is made in the femoral head cartilage
to access the diseased subchondral bone
When combined with a bone grafting procedure, refered as the “Trapdoor”
Procedure
Advantage : Exposure allows a direct evaluation of the cartilage surface &
underlying diseased femoral head segment & allows for
precise bone graft placement.
Disadvantage : Demanding technical nature
Iatrogenic cartilage damage & osteonecrosis
88. Types of Bone Grafts
Nonvascularized Grafts Vascularized Grafts
Nonvascularized cortical 2. Local pedicled grafts,which
bone grafts are typically do not require microvascular
prepared as several struts
that provide structural reanastomosis
support under the articular eg :Muscle-pedicle bone grafts
surface within the evacuated Vascularized pedicle bone
segment grafts
This construct is often
augmented with cancellous 6. Free vascularized grafts,
bone graft in an effort to which require a
improve its osteoconductive microvascular
and/or osteoinductive reanastomosis.
properties eg: Free vascularized fibula
graft
90. Muscle-Pedicle Bone Grafts
Baksi et al (1991) => results in treating 68 hips
with a variety of muscle-pedicle bone grafts
The preferred techniques were the tensor fascia
lata-iliac crest graft anteriorly & the quadratus
femoris posteriorly.
Of note, 82% of the hips treated in the series
demonstrated some degree of collapse
At a mean follow-up of 7 years, there were good
to excellent results in 83% of cases
91.
92. The harvested fibula with marbleized muscle attached confirming an
extraperiosteal dissection. The peroneal artery & two accompanying
veins
93. Proximal Femoral Osteotomies
The main rationale proposed for the efficacy of
osteotomies is the biomechanical effect of
moving the collapsed/necrotic segment of the
femoral head from the principal weight-bearing
area of the hip to an area that bears less/no
direct weight and to allow weight-bearing contact
to now happen in an area of relatively normal
bone and cartilage
94. Proximal Femoral Osteotomies
Categories:-
Valgus or varus osteotomies usually
combined with flexion or extension
Transtrochanteric rotational osteotomies
95. Proximal Femoral Osteotomies
Indications:-
For varus or valgus osteotomies depend
on the location & size of the lesion
Osteotomies may be used for both
precollapse & postcollapse without
notable acetabular involvement
96. VALGUS OSTEOTOMY WITH
FLEXION
• when the necrotic segment is located in
the anterosuperior part of the femoral
head with less than 20% posterior
involvement.
• Optimal patient population would be those
that are less than 45 years of age and are
not on steroids or chemotherapy
99. ROTATIONAL OSTEOTOMIES
• Sugioka first reported a transtrochanteric
transposition osteotomy with anterior
rotation of the head and neck of
the femur
100. ROTATIONAL OSTEOTOMY
before rotation
After rotation
Transposition of the necrotic focus to the ant. & inf. part of the femoral head away
from the weight-bearing area as a result of the ant. rotation of the head
102. Hip Resurfacing Procedures
Femoral & Acetabular Surface Replacement & Hemi-
Surface Replacement for Osteonecrosis of the Hip
Indications :-
Later stages of osteonecrosis (University of Pennsylvania
Stage III–VI)
> 30% femoral head involvement
103. Metal-on Polyethylene Resurfacing
Paltrinieri & Trentani (Italy) & Furuya (Japan) (1971)
independently were the first to perform metal-on polyethylene
resurfacing
Townley introduced a total articular resurfacing arthroplasty
(TARA; Depuy, Warsaw,IN) that resurfaced the femoral head
with a metal component while replacing the articulating surface
of the acetabulum with a thin, plastic shell inserted with cement
Metal-on-polyethylene resurfacing yielded
unacceptably high failure rates. The
polyethylene-induced osteolysis resulting
from the mating of large metal femoral
head components with thin diameter
acetabular cups
105. Total Hip Replacement
TOC for advanced osteonecrosis of the hip (University of
Pennsylvania Stages IVB–VIC)
Excellent pain relief & functional improvements
More recent studies at intermediate follow up up to 10
years have demonstrated similar survivorship compared
to total hip replacement for osteoarthrosis.
108. Femoral Endoprosthesis
Initial changes are in the
femoral head and not the
acetabulum
Replacing the femoral
head would also be more
conservative than the
additive procedure of
acetabular reconstruction,
allowing for later simple
conversion to total hip
arthroplasty
109. Arthrodesis
Mostly a salvage procedure in contemporary orthopedics
In the patient with significant pain & disability & in whom
nonsurgical T/t has failed with a contraindication to
prosthetic replacement
Clinical success can be achieved as it may relieve hip pain
The recommended position is 0° to 5° of adduction, 25° to
30° of flexion & 0° to 15° of external rotation
Later revision to a THR has a significant complication
rate with less functional outcome
110. Resection Arthroplasty
T/t of last resort
Complete resection of the head & neck of the femur
Can achieve a good range of pain-free motion & will be able to
function reasonably well for most activities of daily living
The use of a shoe lift is generally necessary as a result of the
shortening of the extremity, which averages approximately 1.5
inches
There will be a noticeable abductor lurch & patients will
require some form of assistive device for ambulation
Indication:- patient with severe pain and disability who is not a
111. Acrylic Cement Injection
Debriding the necrotic zone then elevating & supporting the
collapsed segment by the injection of cement
Wood and coworkers reported on very preliminary results 21
of 20 cases
All patients realized immediate pain relief with improved hip
scores, with 3 patients undergoing early conversion to total hip
arthroplasty
Relatively invasive but may have the advantage of maintaining
femoral head congruity
Long-term results with perhaps a randomized controlled series
will be necessary if this is a viable alternative to reconstructive
surgery
112. POROUS TANTALUM ROD INSERTION
A novel approach in T/t of stage I & II precollapse osteonecrosis
This rod functions analogously to a Cortical Strut Graft allowing
structural & osteoconductive properties
114. Sir Astley Paston COOPER
1768–1841
“Young medical men find it so much easier to speculate then to observe.
Nothing is known to our profession by guess. There is no short road to
knowledge. Observations on diseased living, examinations of the dead &
experiments upon living animals are the only sources of true
knowledge.”
delicate, sclerotic, raylike branchings emanating in a radial fashion from the central dense band
Axial CT scan of a patient with avascular necrosis of the femoral head (same patient as Images 8-12) shows clumping and distortion of the central trabeculae representing the asterisk sign (arrowhead) and an adjacent low-density region (arrow) representing the reparative zone.
To minimize the chance of fracture, place patients on crutches until there is clinical, radiographic, and MRI evidence of resolution. This may require 4–6 months. This condition affects and these patients have no associated risk factors as in osteonecrosis. In women, it classically develops, and the incidence of fracture is greater than in men. The disease rarely involves both hips at the same time. Occasionally, the opposite hip is affected months or years later. It is difficult to make a definitive diagnosis on the basis of standard radiographs because the only abnormality is mild osteopenia of the femoral head and neck.
The improvement observed in hips treated with CD plus demineralized bone matrix (DBM), although not statistically significant, may be clinically significant.
(citric acid, sodium citrate, and dextrose).
This is because symptomatic ON is characterized by an elevated intramedullary pressure & creating a hole in the cortex & cancellous bone of the proximal femur has been observed to immediately reduce that pressure (personal observation).