1. Avascular Necrosis –
A practical approach
Girish Yeotikar
Arjun Wadhwani
Vinod Naneria
Choithram Hospital & Research Centre,
Indore, India

2. Osteonecrosis –AVN
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 – 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 – suspicion ?
• High degree of suspicion in a patient C/o
anterior HIP pain, especially with:-
H/o Cortisone – For -- Skin, Eye, Liver,
Asthma, RA, Weight gain, PID
H/o Alcohol abuse
Traumatic - # N/F, D/ of F, # Acetabulum
Hemoglobinopathy – 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

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 – Head in Head sign
• Crescent sign
• Collapse
• Joint effusion
• Involvement of actabulum
• Status of other hip
• Marrow infiltrating disease

10. MRI T1 image
•  signal from ischemic
marrow
• Single band like area
of low signal intensity.
• 100% sensitivity
• 98% specificity

11. Double Line sign – 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 –ve in 20%.
• Collapse correspond to Ficat 3.
• TOH may be Subchondral femoral
head stress fractures.

13. Normal
AVN
TOH

14. Diagnosis Early Stage Osteonecrosis
Direct Risk Factors Associated Risk Factors
Traumatic fracture / dislocation Corticosteroid use
Sickle cell disease Alcohol abuse
Radiation Tobacco abuse
Chemotherapy SLE
Myeloproliferative disorders Organ transplant
Thalassemia Gastrointestinal
disorder
Caisson disease Pregnancy, Genetic
inheritance, Coagulation
deficiency

15. Pathophysiology
• Acute vascular interruption:
• Fracture
• Dislocation
• Altered lipid metabolism:
• Corticosteroids.
• Alcohol
• Intravascular coagulation:
• Heamoglobinopathy, familial thrombophilia,
hypercholesterolemia, allograft organ rejection,,
infection, malignancy, or pregnancy.

16. Time Line
• Death of hematopoietic cells - Ischemic insult – 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 – 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

23. Association Research Circulation Osseous quantification

24. Relationship with weight bearing dome

25. Japanese Investigation Committee
Type 1 –
Line of
Demarcation
In relation to
Wt.bearing
Type 2-
Partial
Collapse
Type 3
Cyst
A- central
B peripheral

26. Kerboul:- combined necrotic angle –
AP LAT

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
 60%, 100%
 36%, - 59% 93%
 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 – Head not collapsed
Preservation or sacrifice

35. The basic question ?
• Head preservation – 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 – with collapse
• Varus osteotomy
• Valgus osteotomy
• Sugiako anterior rotation
osteotomy

37. The basic question ?
• Head sacrifice –
• Surface replacement (Birmingham's)
• Non – cemented THR
• Cemented THR
• Cemented / Non cemented Bipolar
• Non cemented AMP
• Girdle Stone – 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 – 50, stage 2 – 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 body–associated 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

47. 35 yr. F, post delivery
1992

48. FU - post delivery pelvis
July 2000

49. 35 years F, post delivery AVN - 1988

50. Same pt. post delivery AVN
July 2000

51. 55, Male
alcohol - AVN

52. Same pt. Fibula strut graft

53. FU of the same Pt.

54. AVN – Post Hip dislocation 2001

55. Post Dislocation FU- 2006

56. 2006

57. Girdhar Gupta 2004Post cortisone 25 M - 2004

58. Post cortisone 25 M

59. Post cortisone 25 M - 2005

60. Post cortisone 25 M -2006

61. Post cortisone 30 M - 2003

62. Post cortisone 30 M

63. Post cortisone 30 M 2009

64. Post cortisone 30 M 2009

65. Post cortisone 35 M 2001

66. Post cortisone 30 M – Fibula strut graft

67. 2008
2003
Post cortisone 30 M - 2008

68. 2008

69. R. V. - 2001

70. MRI-R. 27 F, 2001

72. R.V. After 6 months

73. R.V. After one year

74. S.L. 40 M – post Cortisone

75. S.L. 40 M – post Cortisone
Bilateral grafting

76. Ashok 2001

77. Pre OP
Post OP

79. D.C. 3 yrs PO - 2001

80. 2008 2008
D.C. 3 yrs PO - 2008

81. 2008

82. 2008

83. G.24 M 2000

86. 2008

87. 2011

88. 2011

89. P.G. 30 M, cortisone induced - AVN
Cancellous Bone grafting

91. 2003 – P.G.

92. 2007 – P. G.

93. 2007

96. Technique of Cancellous Bone grafting
- Localization in C-arm
- Guide wire in to lesion
- Cannulated drilling
- Curettage
- Interlocking sleeve
- Cancellous iliac graft
- Packing with impactor/screw driver

100. Vinod Nagar

108. After 3 months

109. M. 50 M CRF
transplant left hip
1997
core decompression
3 years post op Oct.
2000

110. Vascularised Free Fibula Graft
“Healing Construct”
• Decompression of Femoral Head
• Removal of Necrotic Bone
• Grafting of defect with cancellous graft
• Viable cortical Bone strut to support
subchondral bone.
• Age 20 – 50, stage 2 – 4

111. Summaries of cases with head
preservation by free fibula grafting

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.

115. K. K. 35 M AVN 1983
Osteotomy

116. 19891983
K. K. 35 M AVN

117. K. K. Aug. 2000

118. R. J. 30 f post delivery left hip 1985

119. R.J. post delivery left hip 1989

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 – came for removal of implants
1997
2000
2005
Osteotomy

121. 2009

122. 2009

123. 2009

124. A. 22 f CRF transplanted
2000

125. After 2 years

126. Replacement - options
• Hemiarthroplasty
• Bipolar arthroplasty
• Surface replacement
arthroplasty.
• Newer material for THR ceramic
on ceramic
• Non cemented / cemented THR

127. Post collapse
Late-Collapse - symptomatic
treatment till resurfacing or
THR necessary
Guide-lines for management

128. K. - 1992

129. K. 35 f 1999 after removal plate

130. Bipolar Replacement on right side

131. AMP Replacement on left side 2002

132. 2011

133. 2011

134. S, 35 F 2008 2009

135. 2009 2011

136. 2011
2011

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.

139. M. post alcohol AVN Bil THR 1991

140. M. Bil. THR 9 year post-op. Nov 2000

141. B. 19 yrs, F, post cortisone

142. Non Cemented THR

143. AVN – Post # Neck Femur
1988
2002
20061990

144. R. B. – 45 F

145. R. B. – 45 F

146. Bhalchand
AMP – Rt - 1988
THR – Lt - 1991

147. 2005 Poly wear

148. 2007

150. THR removed due to persistent pain cause?
AMP still working

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

154. Weight gain medicines

155. Performance
improving
drugs

156. Carry Home Message –
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 –
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
DISCLAIMER

159. Thank You
The End Of AVN Story