MULTIDISCIPLINRY NATURE OF THE ENVIRONMENTAL STUDIES.pptx
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Avascular necrosis of hip
1. Avascular Necrosis â
A practical approach
Girish Yeotikar
Arjun Wadhwani
Vinod Naneria
Choithram Hospital & Research Centre,
Indore, India
2. Osteonecrosis âAVN
The death of cell
components of bone &
bone marrow from
repeated interruptions
or a single massive
interruption of the
blood supply to the
bone.
3. AVN â responsible for
⢠15,000 new cases of AVN/year
⢠10% THR in USA.
⢠10% undisplaced # neck Femur
⢠30% displaced # neck Femur
⢠10% Dislocation Hip
4. Management protocol
⢠Early diagnosis
⢠Radiological evaluation
⢠Rule out other causes
⢠MRI
⢠Quantification
⢠Treatment algorithm
5. Early Diagnosis â suspicion ?
⢠High degree of suspicion in a patient C/o
anterior HIP pain, especially with:-
H/o Cortisone â For -- Skin, Eye, Liver,
Asthma, RA, Weight gain, PID
H/o Alcohol abuse
Traumatic - # N/F, D/ of F, # Acetabulum
Hemoglobinopathy â Sickle / Myelo-infiltrating
Even with normal x-rays
6. Radiology- sequential Changes
⢠Crescent Sign
⢠Osteoporosis
⢠Sclerosis
⢠Cystic changes
⢠Loss of spherical weight
bearing dome
⢠Partial collapse of head
⢠Secondary Osteoarthritis
7.
8. Magnetic Resonance Imaging
⢠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,SLE & other collagen
disorders.
9. MRI - Findings
⢠Bone Marrow edema
⢠Double Line â Head in Head sign
⢠Crescent sign
⢠Collapse
⢠Joint effusion
⢠Involvement of actabulum
⢠Status of other hip
⢠Marrow infiltrating disease
10. MRI T1 image
â˘ ďŻ signal from ischemic
marrow
⢠Single band like area
of low signal intensity.
⢠100% sensitivity
⢠98% specificity
11. Double Line sign â T2 image
⢠A second high
signal intensity
seen within the line
seen on T1 images.
⢠Represent
hyper vascular
granulation tissue
12. Pearls & pitfalls on MRI
⢠Involve antero-lateral aspect.
⢠Articular cartilage intact initially.
⢠Sagittal images are more accurate.
⢠Double line sign may be âve in 20%.
⢠Collapse correspond to Ficat 3.
⢠TOH may be Subchondral femoral
head stress fractures.
16. Time Line
⢠Death of hematopoietic cells - Ischemic insult â Bone
scan + 6 -12 hours
⢠Death of Osteocytes 12- 48 hours
⢠Bone scan becomes negative once remodeling occur.
⢠MRI will become positive after 5 days due to death of
fat cells, but it will remain positive till complete healing.
⢠Focal MR abnormality and diffuse marrow edema can
been by 6-8weeks
Histology is the only method to confirm AVN
Empty lacuna â dead osteocytes
17. Preventive measures
⢠Judicial use of steroids
⢠Use of Statin in cases of short/long term
high dosage of steroids.
⢠Public awareness for avoiding drug for rapid
weight gain and decrease libido (anabolic
steroids).
⢠Discourage excessive alcohol and smoking.
⢠Patients at high risk informed about the
possibility of AVN, & to report symptoms as
soon as possible to facilitate early diagnosis
and treatment.
18. Pharmacological Agents
⢠lipid-lowering agents,
⢠Anticoagulants, Prostacyclin analogs, may work by
inhibiting aggregation of platelets, thus enhancing
blood flow to ischemic bone areas and potentially
promoting healing.
⢠Statins, is based on the association of high levels of
blood lipids and an increased risk of the development
of osteonecrosis.
⢠Bisphosphonates to decrease osteoclastic activity and
permit bone formation via the osteoblastic process.
19. Pharmacological Agents
⢠The clinical failure rates for the various
pharmacological therapies have ranged from 0% to
10%.
⢠In one of these studies, Pritchett reported that the
prevalence of osteonecrosis was only 1% in patients
who were receiving corticosteroid therapy and who
received concurrent statin therapy.
⢠While the results of the pharmacological studies
appear promising, the reported results were limited to
only short-term to midterm follow-up.
20. 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
21. 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
22. 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
25. Japanese Investigation Committee
Type 1 â
Line of
Demarcation
In relation to
Wt.bearing
Type 2-
Partial
Collapse
Type 3
Cyst
A- central
B peripheral
27. 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
28. 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
29. ⢠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
30. Stulberg et al CORR 186: 137-153, 1991
Randomised prospective study, 55 hips
in 36 pts
Good Results CD No Tx
⢠Stage 1 70% 20%
⢠Stage 2 71% 0%
⢠Stage 3 73% 10%
31. Kaplan-Meier survival curves
Core 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
32. 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.
33. Proximal Femoral Osteotomy
Intact weight bearing
area after transposition %Success
ď 60%, 100%
ď 36%, - 59% 93%
ď 21% - 35% 65%
< 20% 29%
More normal bone at wt. bearing area
Better the result of Osteotomy
34. Irrespective of Classifications
Basic questions for treatment?
⢠How early to interfere?
⢠How much to interfere?
⢠Can we wait?
⢠When to start , if at all,
Bisphosphonate?
Head collapsed â Head not collapsed
Preservation or sacrifice
35. The basic question ?
⢠Head preservation â without collapse
⢠No Tx
⢠Drilling alone
⢠Core decompression
⢠CD + Cancellous / free fibula graft
⢠CD + Muscle pedicle graft
⢠CD + vascularized fibula graft
36. The basic question ?
⢠Head preservation â with collapse
⢠Varus osteotomy
⢠Valgus osteotomy
⢠Sugiako anterior rotation
osteotomy
37. The basic question ?
⢠Head sacrifice â
⢠Surface replacement (Birmingham's)
⢠Non â cemented THR
⢠Cemented THR
⢠Cemented / Non cemented Bipolar
⢠Non cemented AMP
⢠Girdle Stone â Excision arthroplasty
38. Pre-Collapse Hips
⢠Check extent of lesion
If 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
39. Pre-Collapse Hips
Location of lesion
Type A (medial) - observation with periodic
followup
i. Type B,C - Core decompression
Other considerations:
i. Diagnosis: SLE do worse
ii. Continued Steroid / Alcohol : Do Worse
iii. Age and compliance
Guide-lines for management
40. 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 â 50, stage 2 â 4
41. Surgery - Core decompression
⢠Improves circulation by decreasing intramedullary
pressure and preventing further ischemia and
progressive joint destruction.
⢠The best results vary from 34-95%, which is
significantly better than results of conservative
treatment.
⢠The best results are obtained when treating
patients with early AVN (precollapse).
⢠Core decompression is also effective for pain
control.
42. Surgery - Core decompression + BG
⢠Bone graft options include
⢠structural cortical strut
⢠Cancellous bone graft
⢠Muscle-pedicle vascularized bone graft
⢠Free vascularized fibular graft.
43. Surgery - Core decompression + BG
⢠Bone grafting is combined with the following:
⢠Core decompression, which may interrupt the
cycle of ischemia
⢠Excision of sequestrum, which may inhibit
revascularization of the femoral head.
⢠Period of limited weight bearing.
⢠The best results have been reported with free
vascularised bone grafts. Success rates of 70%
and 91% have been reported in 2 small series.
44. Advantages
⢠Advantages of free vascularized grafts compared to
total hip arthroplasty include the following:
⢠Healed femoral head may allow more activity.
⢠No foreign bodyâassociated complications occur.
⢠If performed during early AVN, lifelong survival of
the femoral head is possible.
⢠The patient has the option of total hip arthroplasty in
the future.
45. Disadvantages
⢠Disadvantages of free vascularized grafts
include the following:
⢠Longer period of recovery
⢠Less complete pain relief.
⢠Variable success rate
⢠Lack of effectiveness in advanced
disease
109. M. 50 M CRF
transplant left hip
1997
core decompression
3 years post op Oct.
2000
110. Vascularised Free Fibula Graft
âHealing Constructâ
⢠Decompression of Femoral Head
⢠Removal of Necrotic Bone
⢠Grafting of defect with cancellous graft
⢠Viable cortical Bone strut to support
subchondral bone.
⢠Age 20 â 50, stage 2 â 4
112. Post-Collapse Hips
1.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
113. Osteotomy
⢠Several osteotomy procedures
have been tried with variable
success.
⢠Intertrochanteric osteotomies
have been performed in patients
with posttraumatic AVN.
114. Osteotomies
⢠Transtrochanteric rotational osteotomy involves
rotation of the femoral head and neck on the
longitudinal axis. The necrotic anterosuperior part of
the femoral head becomes posterior, and the weight-
bearing force is transmitted to what was previously the
posterior articular surface, which is not involved in the
ischemic process.
⢠In 1992, Sugano and colleagues reported excellent
results in 56% of patients who underwent this
procedure.[13] Transtrochanteric rotational osteotomy is
technically demanding.
120. M.- 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 side
2005 â came for removal of implants
1997
2000
2005
Osteotomy
137. Total hip arthroplasty
⢠Most patients with advanced disease
(stage III and above) require total hip
arthroplasty.
⢠Total hip arthroplasty provides excellent
pain relief for many years, although most
young patients require repeat surgery.
138. Total hip arthroplasty
⢠With high failure rates (10-50% after 5 y),
patients with AVN will probably need a
second total hip arthroplasty during their
lifetime.
150. THR removed due to persistent pain cause?
AMP still working
151.
152. Study/year/
design
Technique Hips Precollapse Failures Postcollapse Failures
Maniwa et al. CD w/wo NVG 26 26 8 (30.8%)
Steinberg et al. D/NVG/EStim 312 198 63 (31.8%) 105 48 45.7%)
Gangji et al.) CD 8 8 2 (25%)
CD/BMG 10 10 0 (0%)
Hernigou et al CD/BMG 189 136 23 (16.9%) 7 7 (100%)
Yang et al. CD/BLAC 56 48 5 (10.4%) 8 4 (50%)
Tsao et al. CD/TR 113 94 18 (19.1%) 19 4 (21%)
Shuler et al. CD/TR 22 22 3 (13.6%)
Kim et al. VFG 23 10 1 (10%) 13 7 (53.8%)
NVFG 3 10 5 (50%) 13 11 (84.6%)
153. Psychosocial - AVN
⢠Drugs for gain in weight.
⢠Steroid like drugs
⢠Herbal/ Aurvedic/ Chinese/
⢠Drugs for improved performance
in sex.
These drugs may be
mixed with steroids
which may cause AVN
156. Carry Home Message â
Anterior Hip pain + Cortisone
⢠Anterior hip pain in a young adult male should be
consider as AVN till proved otherwise.
⢠History of Cortisone may be in very small dosage or
for a very short time can cause AVN in sensitive
patient who have deficiency of Cytochrome P450 3A
(steroid-metabolizing hepatic enzyme).
⢠suppression of CYP3A activity significantly increased
vulnerability to steroid-induced osteonecrosis, while
increased CYP3A activity reduced this vulnerability.
157. Carry Home Message â
Management Phylosophy
⢠Early diagnosis
⢠Early decompression
⢠Calcellous bone graft
⢠Bisphosphonate
⢠Osteotomy
⢠Replacement arthroplasty
158. ⢠Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India, during last
32 years.
⢠It is intended for use only by the students of orthopaedics.
⢠Many GIF files are taken from Internet.
⢠Views and opinions expressed in this presentation are personal.
⢠Depending upon the x-rays and clinical presentations viewers
can make their own opinion.
⢠For any confusion please contact the sole author for clarification.
⢠Every body is allowed to copy or download and use the material
best suited to him.
⢠I am not responsible for any controversies arise out of this
presentation.
⢠For any correction or suggestion or copy right violation please
contact naneria@yahoo.com
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