avascular necrosis

Update in Update in Osteonecrosis of Osteonecrosis of

Femoral HeadFemoral Head

Scope Scope

DefinitionDefinition EtiologyEtiology PathogenesisPathogenesis DiagnosisDiagnosis TreatmentTreatment

Definition Definition

Disease of impaired osseous blood flow in which a circumscribed area of bone becomes necrosis

EtiologyEtiology

Traumatic Non-traumatic

Steroid usage Alcohol Blood disease

Sickle cell anemia Hypofibrinolysis

Caisson disease Connective tissue disease Idiopathic 15-20%

EtiologyEtiology (Non-traumatic)(Non-traumatic)

EtiologyEtiology Steroid usage

SLE incidence 15-44% Oinuma K.

คนไข้� SLE 72 ราย high dose (>30mg/d) พบ AVN 44% ใน 3 เดื�อน

Osteonecrosis in patients with systemic lupus erythematosus develops very early after starting high dose corticosteroid treatment. Annals of Rheumatic Diseases.2001;60(12):1145-8.

EtiologyEtiology

Steroid usage - 6-8 years (range 1-19) - Kidney transplant AVN 4.5% - 80% Bilateral

EtiologyEtiology Koo KH, et al

ผู้��ป่�วย 22รายเกิ�ดื AVN เฉลี่��ย 5928 mg(1,800-15,505 mg) Average 5.3 m.(1-16 m) 21/22 รายเป่�นใน 1 ป่�แรกิ

Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment. Clin Rheumatol 2002 Aug:21(4):299-303

Steroid usageSteroid usage

Pathophysiology: 1)Direct cellular toxicity

2)Abnormal fat metabolism-Adipocyte hypertrophy-Fat embolism

EtiologyEtiology

Marston SB, et al Solid organ transplant (kidney+liver) 52 pt. AVN femoral head 11% (20%) AVN in 10 months MRI screening in the first year

EtiologyEtiology Ferrari P, et al.

Homozygous 4G/4G PAI-1 genotype. Ries MD.

HIV infection (risk factor of AVN)

Association between human immunodeficiency virus and osteonecrosis of the femoral head. J Arthroplasty 2002 Feb: 17(2):135-9

PathogenesisPathogenesis

Infarction theory Fat embolism theory Accumulative cell stress theory Progressive ischemia theory Immunologic reaction

DiagnosisDiagnosis History Physical examination Laboratory test

CBC, ESR R/O infection Cortisol level

Radiological examination

History History

A high index of suspicious is essential

An associated risk factor The most common presenting

symptom is a deep pain in the groin

Exacerbated by activity

Physical examinationPhysical examination

Pain on internal rotation Decrease ROM Hip abductor weakness (G.

medius) Shortening of limb

Plain film X-Plain film X-rayray

AP pelvis, frog leg

Crescent sign Secondary OA

change

Technetium bone scan (Tc Technetium bone scan (Tc 99)99)

Preradiographic phase AVN Decrease uptake Sensitivity and specificity <

MRI SPECT (Single-photon emission

computed tomography) sensitivity 100% in renal

transplant pt.

BONE SPECTBONE SPECT

32 AVN of femoral head SPECT detect 32/32 -> 100% sensitivity MRI detect 21/32 -> 66%

sensitivity

(The Journal of Nuclear Medicine. 2002;43(8):1006-1011)

MRIMRI Investigation of choice Decrease signal Screening T1 coronal scan

CT scanCT scan Arthroscopic examinationArthroscopic examination

Ficat’s stagingFicat’s staging Clinical Plain

film MRI

Stage O No pain normal abnormal

Stage I pain normal +

Stage II + crescent’sign

+

Stage III + Collapsed femoral head

+

Stage IV + Narrow joint space+acetabulum

+

normalnormal scleroticsclerotic

Crescent signCrescent sign Collapse Collapse

AcetabularAcetabular involvementinvolvement

Severe jointSevere jointdestructiondestruction

TreatmentTreatment Conservative

- Temporally non weight bearing

Electrical stimuli Surgery

Joint preserving procedure

prosthetic replacement

TreatmentTreatment

Conservative treatment stage I-II NWB with crutches (6 wks) analgesic+exercise F/U 2 years 80% poor result

Musso, et al. Result of conservative management of osteonecrosis of the femoral head. A retrospective review. Clin Orthop 1986 June; 207: 209-215

Result of nonoperative RxResult of nonoperative Rx 55 AVN / nonoperative Rx

92% radiographic progression 84% arthroplasty, Av. Time 21

months

(Steinberg. Clin Orthop;1989) 15 AVN / nonoperative Rx

100% collapse, Av. Time 23 months (Bradway and Morrey. J

Arthroplasty;1993)

Joint preserving procedureJoint preserving procedure

Core decompression Osteotomy Free vascularized fibular/ iliac g

raft Arthrodesis Arthroscopic debridement

(+core)

TreatmentTreatment

Core Decompression Decrease BMP (bone marrow

pressure) Increase venous drainage Promote vascular ingrowth Bone graft, autologous bone marrow Treatment of choice stage I-II

Core DecompressionCore Decompression

Result of core Result of core decompressiondecompression

133 AVN, stage I+II, F/U 9.5 years90% successful clinical result79% no radiographic progression (Ficat. JBJS;67B:3-9:1985)

204 AVN, F/U 3 yearsno additional operative Rx was necessary

96% stage I77% stage II60% stage III

(Zizic and Hungerford. Textbook of Rheumatology Ed 2, Vol.2:1689-1710)

Electrical stimulationElectrical stimulation Goal: Enhance bone formation and fracture healing Alone or as an adjunct to other surgical procedure PEMP (pulsing electromagnetic fields)

-more effective than symptomatic Rx in precollapse and minimally collapse

-as effective as core decompression in precollapse

-more effective as core decompression in minimally collapse

OsteotomyOsteotomy

Shift the necrotic segment out of the region of major weight bearing and replace it with normal bone and cartilage

Early to intermediate stage that acetabular cartilage is unaffected

Femoral OsteotomyFemoral Osteotomy Candidate

< 40 years old Small lesion (< 200

degrees) Mobile hip No longer taking steroid

Difficulty for THR Removal of implants after

union

Result ofResult of Ostetomy Ostetomy Sugioka Y ( Sugioka Y (CORR.CORR.19198484)

158 113hip (ราย ) มี� success rate 86-95 %

(1992 , 295 pts, 79%, ave F/U 11 yrs)

Inao S (CORR. 1999) 14 hips( 12 ราย ) F/U

- 1017 ป่� มี� 3 ราย >THR ถ้�า Collapse 2<mm จะไดื�ผู้ลี่ ดื�ที่�� 15 ป่�

TreatmentTreatment Vascularized bone graft - fibular, iliac crest - revascularized

Vascularized bone graftVascularized bone graft Goal:

Decompress the femoral head Remove necrotic bone Fill necrotic defect with

osteoinductive cancellous bone graft Support subchondral bone with strut

graft Enhance revascularized process

Vascularized bone graftVascularized bone graft

Disadvantage: Technical demand A few centers have significant experience with this technique Well-trained microvascular surgeon More complication

Vascularized bone graftVascularized bone graft

Advantage: The result is better than core

decompression in stage II, III

(Ficat classification)

Result of Vascularized bone Result of Vascularized bone graftgraft

-Urbaniak JR (JBJS. 77 A.1995) mean survival rate= 88% ในผู้��ป่�วย

stage I , II Judet H (CORR.2001) FU 18 ป่�

พบว%า 80% ข้องผู้��ป่�วย 60 ราย stage I,II ย'งไดื�ผู้ลี่ดื�อย�%

Prosthetic replacement Prosthetic replacement surgerysurgery

Limited resurfacing arthroplasty

Resurfacing arthroplasty Hemiarthroplasty Total hip replacement

Limited Resurfacing Arthropl Limited Resurfacing Arthroplastyasty

2001Mont MA (CORR. , J. Arthroplasty2001

ผู้��ป่�วย 30 รายใน stage III, IV เป่ร�ยบเที่�ยบกิ'บผู้��ป่�วยอ�กิ 30 ราย ใน stage เดื�ยวกิ'น แต่%ใช้�ว�ธี�กิารเป่ลี่��ยนที่'+งข้�อ

7FU ป่� พบว%า 90% แลี่ะ 93% ข้องที่'+ง 2 ว�ธี� ย'งคงใช้�ไดื�ดื�อย�%

Siguier T (CORR.2001) ผู้��ป่�วยstage III 26 ข้�อ แลี่ะ stage IV 10 ข้�อ พบว%าที่��FU 4 ป่� มี� 9 ราย ที่��ต่�องเป่ลี่��ยนเป่�น THR

Result of Result of Limited Resurfacing Limited ResurfacingArthroplastyArthroplasty

Hemisurface arthroplastyHemisurface arthroplasty

Hemisurface or partial Hemisurface or partial resurfacing arthroplastyresurfacing arthroplasty

Time-buying procedure for young and active patient

Adequated bone quality and relative normal articular cartilage

Bone stock preservation and intact intramedllary canal

Survivorship 81% at 5.1 years Survivorship 61% at 10 years (Amstutz HC. Semin Arthroplasty ;9:261,1998)

HemiarthroplasHemiarthroplastyty

Chan YS (CORR.2000) ได้�เปรี�ยบเที�ยบผลการี

รี�กษาโด้ยใช้� Bipolar ก�บ THR ในคนไข้�คนเด้�ยวก�นพบว�า 24 ใน

28 ข้�างข้อง bipolar และใน 23

ใน 28 ข้�างข้อง THR ได้�ผลเป�นที� พอใจเมื่# อติ%ด้ติามื่ผลไปเฉล� ย 6.

4 ป'

Treatment

Total hip arthroplasty - femoral head + acetabulum - stage IV - survivorship in young patient is

less than in older patient

Total Hip Arthroplasty

Total Hip Arthroplasty

Ficat Stage I

Rx. 1. Conservative 2. Core decompression

Ficat stage II

Rx. 1. Conservative 2. Core decompression 3. Others

Ficat stageIII

Rx. 1. Conservative 2. Hemi arthropl asty 3 . Others

Ficat stageIV

Rx. 1.Conservative 2. THR 3.Arthrodesis

Thank You