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Natasha Holder, MD, MSc. PGY-1.  Osteonecrosis of the femoral head ◦ Etiology, Pathogenesis  Clinical Presentation  Diagnosis  Classification of AVN.

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Presentation on theme: "Natasha Holder, MD, MSc. PGY-1.  Osteonecrosis of the femoral head ◦ Etiology, Pathogenesis  Clinical Presentation  Diagnosis  Classification of AVN."— Presentation transcript:

1 Natasha Holder, MD, MSc. PGY-1

2  Osteonecrosis of the femoral head ◦ Etiology, Pathogenesis  Clinical Presentation  Diagnosis  Classification of AVN  Management of Stage I and Stage II ◦ Non-Operative ◦ Core Decompression ◦ Bone Grafting ◦ Osteotomy

3  AKA avascular necrosis or aseptic necrosis  Disruption of the blood flow to the femoral head (traumatic or nontraumatic)  Commonly affects patients between 20 and 50 years of age  Ultimate goal of treatment of ON of the hip is preservation of the femoral head

4  Trauma  Corticosteroid use  Alcohol abuse  Smoking  Sickle cell anemia  Coagulopathies  Systemic lupus erythematosus  Hypercholesterolemia  Organ Transplantation JAAOS, 1999:

5  Gaucher Disease  Caisson Disease  Radiation Therapy  Arterial disorders  Intramedullary hemorrhages  Chronic Pancreatitis  Hypertriglyceridemia  HIV JAAOS, 1999:

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7  Early in the disease process, the condition is painless  Chief complaint is pain  Localized to the groin area, but it may also manifest in the ipsilateral buttock, knee, or greater trochanteric region.  Painful symptoms are usually exacerbated with weight bearing but are relieved by rest

8  History ◦ High index of suspicion ◦ Risk factors ◦ Groin pain, night pain  Physical Exam ◦ Pain on internal rotation ◦ Pain with active and passive ROM ◦ Decreased ROM ◦ Antalgic gait ◦ Examine the contralateral hip

9  Laboratory tests ◦ R/O systemic disease, coagulopathies  Radiological Tests ◦ Plain film - AP and Frog leg lateral  Cysts, sclerosis or a crescent sign  Crescent sign results from subchondral collapse of the necrotic segment ◦ MRI – Diagnostic Standard ◦ Bone Scan  Special Tests ◦ Bone marrow pressure, venography, biopsy

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11  Non-operative Treatment  Operative Treatment ◦ Core decompression ◦ Non-vascularized bone-grafting ◦ Vascularized bone-grafting ◦ Osteotomy ◦ Limited Femoral Resurfacing Arthroplasty ◦ Total Hip Arthroplasty  Non-operative Treatment  Operative Treatment ◦ Core decompression ◦ Non-vascularized bone-grafting ◦ Vascularized bone-grafting ◦ Osteotomy

12  Restricted weight bearing is NOT an treatment option except in small, asymptomatic lesions outside the weight bearing area  Meta analysis of outcomes of protected weight bearing in 819 patients demonstrated a failure rate >80 % at a mean of 34 months (Mont et al. Clin Orth Relat Res, 1996:169-78)

13  Pharmacological agents: lipid-lowering drugs, anticoagulants, vasodilators and bisphoshonates  Prichett et al. report at a mean of 7.5 years, ON of the femoral head has developed in only 1% of 284 patients who were taking high dose steroids and a statin. (Clin Orthop 2001; 386:173-8)

14  Glueck et al. used enoxaparin (60mg/day for 12 weeks) to treat patients with thrombophillic or hypofribinolytic disorders in early stages of ON  At 2 years, 89% (31/35 hips) had not required surgery and remained at the Ficat I or II stage (Clin Orth Relat Res, 2005:164-70)

15  Bisphosonates inhibit osteoclast activity and thus curtail bone reabsorption  Agarwala et al. first reported the efficacy of bisphosphonates. Showed an improvement in Harris hip scores, retarded progression of of the disease and reduced rate of collapse (Rhemat. 2005:353-59)

16  Agarwala et al. ◦ prospective study ◦ 395 hips treated with 10 mg alendronate/day ◦ F/U 1-8 years ◦ 92% had a satisfactory result (no surgical intervention) ◦ Patients had improvement in clinical function, a reduction in rate of collapse and a decreased requirement for THA ◦ Improvement is marked if treatment is begun in the pre-collapse stages

17  Goal: to decompress the femoral head and reduce the intraosseous pressure  No general agreement on indications or technique  Substantial differences in success rates reported ◦ poor staging of patient pathology ◦ recurrent insults depending on pathology ◦ variations in techniques

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19  Originally employed by Ficat and Arlet to obtain histological specimens  Decompression reduced bone marrow pressure allowing restoration of blood flow  Stulberg et al. (Clin Orthop 1991, 268:140-51) ◦ Prospective, randomised study, 55 hips ◦ 70% success by Harris Hip score with Ficat I, II, or III stage  Koo et al.(JBJS 1995, 77:870-74) ◦ Randomised control trial, 37 hips ◦ Operative Group: 72% progression and 72% of those that progressed required THA ◦ Non-Operative group: 79% progression and 68% required THA

20  Retrospective studies have shown that results of core decompression were substantially worse when there had been collapse of the femoral head preoperatively  Smith et al. (JBJS 1995, 77:674-80) ◦ Retrospective review of 114 hips ◦ Decrease in success rate if the crescent sign had been present ◦ 80% success rate for Ficat I, 20% If crescent sign was present, 0% femoral head collapse

21  Rationale: 1.Decompress the femoral head 2.Removal necrotic bone 3.Replacement with autogenous cancellous bone 4.Support the subchondral bone with a strong and viable bone strut 5.Revascularization the femoral head

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23 Urbaniak et al. (JBJS 1995; 77:681-94) ◦ 103 hips, Mean F/U 7 years ◦ Best results were seen in those with small or medium precollapse lesions. ◦ 11% (2/19) of pre-collapse group were converted to THA ◦ 23% (5/22) of post-collapse group were converted to THA ◦ 39% (24/62) of advanced lesion group were converted to THA Berend et al. (JBJS 2003; 85:987-93) ◦ 224 collapsed hips ◦ 64.5% survival rate at a mean 4.3 years (range 2-12) ◦ Relative risk of conversion to THA was associated with an increased lesion size and the amount of collapse

24  Provides decompression of the femoral head, removal of necrotic bone and structural support and scaffolding to allow repair and remodeling of subchondral bone  3 distinct approaches 1.Core tract grafting 2.Femoral Neck Window - Light bulb procedure. 3.Trapdoor through articular cartilage of head

25 Lieberman et al. 2002; 84:

26 Meyers et al; JBJS 1973:55A,pg 257

27  Rosenwasser et al. (Clin Orthop. 1994:306:17-27) ◦ Described the “light bulb” approach ◦ 87% success rate in a study of 15 hips with a mean F/U of 12 years  Mont et al. (Clin Orthop. 2003: 417:84-92) ◦ 86% success rate in a study of 21 hips, light bulb approach ◦ Harris score >80 and no additional procedures

28  Lieberman et al. (Clin Orthop 2004: 429:139-45) ◦ Retrospective study, 17 hips, Core track method ◦ Used bone morphogenic protein ◦ 14/17 successful result ◦ Harris score >80 and no conversion to THA

29  To remove necrotic or collapsing segment from the principle weight-bearing region  Replace this area with a segment of articular cartilage of the femoral head that is supported by healthy, viable bone  2 Types: ◦ Transtrochanteric Rotational Osteotomies ◦ Intertrochanteric varus/valgus Osteotomies

30  Sugioka et al. ◦ 78% of the 295 hips studied had a successful outcome at a mean of 11 year F/U  Masuda et al. ◦ 69% of 52 hips studied had a successful outcome at a mean of 5 year F/U

31  Best results in young active patients who were not taking corticosteroids, had unilateral involvement with a good preoperative range of hip motion, and had a small lesion without femoral head collapse

32  Less technically demanding  Commonly used in Europe with varying success

33  Merle d’Aubigne et al. ((JBJS(br), 1965; 47:612-33) ◦ Good to excellent pain reduction in 79% of the 75 hips with Ficat II or III. F/U 1 to 6 years.  Mont et al. (JBJS, 1996; 78: ) ◦ Good to excellent Harris hip scores in 76% of the 37 hips studied after treatment with varus osteotomy. F/U mean 11.5 years

34  Drescher et al. (JBJS (Br) 2003;85-B:969-74) ◦ 70 intertrochanteric flexion osteotomies. ◦ The mean follow-up was 10.4 years (3.0 to 20.3). ◦ The overall mean Harris hip score increased from 51 points preoperatively to 71 points postoperatively. ◦ A total of 19 hips (27%) underwent total hip arthroplasty at a mean of 8.7 years after osteotomy. ◦ The five-year survival rate was 90%. ◦ Flexion osteotomy is a safe and effective procedure in Ficat stage 2 and 3, preferably with a necrotic angle of <200°

35  The size of the osteonecrotic lesion was determined to be a critical factor in the rate of success of the osteotomy

36 StageTreatment I (no radiographic changes)Non-Operative, Core Decompression II ( precollapse)Core decompression, Bone grafting, osteotomies

37  The etiology of ON of the hip may have a genetic basis  The interaction between certain risk factors and a genetic predisposition may determine the course of ON in a particular individual  The role of biological agents in altering the natural history of ON remains to be elucidated  Early diagnosis and intervention prior to collapse is key to successful outcomes of joint preserving procedures


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