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avn management
- 1. UNDER GUIDANCE OF DR UMANG AGRAWAL (M.S.ORTHO) BY – DR SANDEEP PATIL 3 YEAR RESIDENT
- 2. TREATMENT PLAN 1)Precollapse or post collapse lesion 2)Size of necrotic fragment 3)Amount of head depression 4)Acetabular involvement courtesy -campbell, john j callaghan
- 3. CONSERVATIVE TREATMENT Observation Medication Protected weight bearing courtesy -campbell, john j callaghan
- 4. Surgical modalities 1)CORE DECOMPRESSION 2) BONE GRAFTING PROCEDURES 3)PROXIMAL FEMORAL OSTEOTOMY 4) HIP RESURFACING ARTHROPLASTY 5)TOTAL HIP ARTHROPLASTY courtesy -campbell, john j callaghan
- 5. CORE DECOMPRESSION Relieves intraosseous pressure and increased vascularity Indication - stage I and IIa ficat and arlet stage (small and medium size precollapse lesions) courtesy -campbell, john j callaghan
- 7. MONT’S PERCUTANEOUS CORE DECOMPRESSION One skin entry point Post operatively protected weight bearing for 6 weeks Followed by full weight bearing courtesy -campbell, john j callaghan
- 8. Advantages minimal invasive technique Femur head sparing procedure Low morbidity courtesy -campbell, john j callaghan
- 9. BONE GRAFTING procedures Standard core track technique Trap door technique Light bulb technique courtesy -campbell, john j callaghan
- 10. Trap door technique courtesy -campbell, john j callaghan
- 11. Trap door technique courtesy -campbell, john j callaghan
- 12. Light bulb technique Risk of fracture courtesy -campbell, john j callaghan
- 13. Advantages Direct evaluation of damage Precise placement of bone graft Disadvantages Technical difficulty Iatrogenic osteonecrosis courtesy -campbell, john j callaghan
- 14. vascularised fibular bone grafting -urbaniak courtesy -campbell, john j callaghan
- 15. courtesy -campbell, john j callaghan
- 16. advantages Healed femoral head may allow more activity No foreign body reaction Possibility of survival of femoral head for life Total hip arthroplasty can be done ultimately disadvantages Long recovery period Less complete relief of pain when compared to total hip arthroplasty courtesy -campbell, john j callaghan
- 17. Proximal femoral osteotomy Young patients Small or medium sized femoral head lesions { <30 %} Idiopathic /post traumatic had better results than alcohol/steroid induced necrosis courtesy -campbell, john j callaghan
- 18. Stage II & III Intertrochanteric osteotomy Varus osteotomy Valgus osteotomy Sugioka rotational osteotomy
- 19. Why does Osteotomy work? Osteotomies improve hip function Increasing contact area / congruency Improve coverage of head Moving normal articular cartilage into weight bearing zone Restore biomechanical advantage / Decreasing joint reactive forces
- 20. Pre-op Evaluation Radiograph Maximum abduction maximum adduction If femoral head sits best VARUS VALGus
- 21. Varus osteotomy • principle • Designed to elevate the greater trochanter and move it laterally while moving the abductor and psoas muscles medially, to restore joint congruity and decrease muscle forces about the hip. INDICATIONS Abduction deformity Painfull adduction Spherical head
- 22. Disadvantages of varus femoral osteotomy Potential to shorten limb Weaken abductors Trendelenburg gait Potential difficulty with stem insertion in future arthroplasty Increases the prominence of the greater trochanter.
- 26. Valgus osteotomy Principle Transfer the center of hip rotation medially from the superior aspect of the acetabulum to increase joint congruity and the weight-bearing area of the femoral head Indications Trendelengburg limb Adduction deformity Painfull abduction
- 30. Sugioka osteotomy Rationale is to reposition part of femoral head to a non weight bearing locale Femoral head & neck is rotated anteriorly Done in pt with only less than 30% of femoral head involvement Technically demanding
- 31. Transtrochanteric anterior rotational osteotomy -SUGIOKA courtesy -campbell, john j callaghan
- 32. RESURFACING ARTHROPLASTY Indication –ficat and arlet stage 3 courtesy -campbell, john j callaghan
- 33. Advantages Large head diameter provides increased stability Preserves bone Straightforward revision Increased range-of-motion More normal gait pattern www.hipresurfacingnewyork.com
- 34. exposure and dissection courtesy -campbell, john j callaghan
- 35. measurements and trial courtesy -campbell, john j callaghan
- 36. Acetubular orientation courtesy -campbell, john j callaghan
- 37. femoral head resurfacing courtesy -campbell, john j callaghan
- 38. courtesy -campbell, john j callaghan
- 39. reaming courtesy -campbell, john j callaghan
- 40. cementing courtesy -campbell, john j callaghan
- 41. Component fixation courtesy -campbell, john j callaghan
- 42. Total resurfacing arthroplasty courtesy -campbell, john j callaghan
- 43. Complications Fracture Component malposition Dislocation Infection Aseptic Loosening www.orthosupersite.com
- 44. POSTOPERATIVE CARE WALKING ON SAME DAY NO ABDUCTION PILLOW REQUIRED FULL ACTIVITY AFTER 6 MONTHS courtesy -campbell, john j callaghan
- 45. Total hip arthroplasty When severe arthritic changes noted on both side of hip, THR is the only option Patient should be well informed of certain need for one or more revsion BIPOLAR HEMIARTHROPLASTY poor results
- 46. Implant Choice Cemented: •Elderly (>65) •Low demand
- 47. Implant Choice Cementless: •Younger •More active •Protected weight- bearing first 6 weeks
- 48. THA Implants
- 49. Radiographic Evaluation of lesion Small Pre-collapsed Large ,collapse Medium Pre-collapsed to early post asymptomatic symptomatic Bone grafting (vascularised or non vascularised) osteotomy Operative technique Femoral head cartilage damage only Limited femoral resurfacing Femoral and acetabular cartilage damage Total hip arthroplasty Observation Pharmological rx or Core decompression Core decompression with or without bone grafting courtesy -campbell, john j callaghan