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