Department of Orthopaedics, Father Muller Medical College

MANAGEMENT OF AVN HIP

Presented by: Dr. Terence
Moderator: Dr. Tils
Investigation:
Routine radiographs
MRI
Scintigraphy

Routine radiographs:
The first signs appear only 6-9months after occurrence of bone death
The changes are mainly due to the surrounding due mainly to reactive
changes in the surrounding(live) bone.
Thus, the classic feature of increased density (interpreted as sclerosis) is a
sign of repair rather than necrosis.
With time, destructive changes do appear in the necrotic segment: a thin
subchondral fracture line (the crescent sign), flattening of the
weightbearing zone and then increasing distortion, with eventual collapse,
of the articular surface of the femoral head.

Crescent sign on Frog leg lateral view(Dan miller view)



Ficat & Arlet Classification
Stage Radiologic criteria
I Normal
II IIA
Porosis/sclerosis/cysts
Normal head contour
IIB
Subchondral fracture-Crescent sign,
Altered contour of femoral head
III Collapse of femoral head
IV OA changes

Combined necrotic angle(Kerboul):
Extent of necrosis in plain radiographs was detrmined by measuring the arc of the
articular cartilage overlying the lesion in both AP & Lateral radiographs.
These two added together have been referred to as combined necrotic angle
Large: > 200
Medium: 160-200
Small: < 160


MRI:
Diminished Intensity Band in the T1 weighted image :
This band represents the reactive zone between living and dead bone and thus
demarcates the ischaemic segment, the extent and location of which are
important in staging the lesion.

Double density line in T2 image:
Representing hypervascular granulation tissue.

Helpful in eliminating a DD: Transient osteoporosis. Transient osteopenia of the
hip is a self-limiting condition that is usually seen in women in the third trimester
of pregnancy and in men in the 5
th
& 6
th
decades of life. MRI of these patients
shows edema into the femoral neck and metaphysis, which is not common with
osteonecrosis.

A: Serpiginous line of low intensity in T1 Transient osteopenia:
B: Double-line sign, with the outer dark Low-intensity signal representing bone
line representing the sclerotic rim & the marrow edema affecting femoral head
inner high intensity, signal line neck & metaphysis.
representing hypervascularity of the
repair.
Shimizu et al. classification:
The risk of femoral head collapse (atleast over a period of 23 years) was related
mainly to the extent(the area of the coronal femoral head image
involved) and location(the portion of the weight bearing surface) in the initial
MRI.
Three grades:
(1) lesions occupying less than one-quarter of the femoral head coronal
diameter and involving only the medial third of the weight-bearing surface
rarely go on to collapse;
(2) lesions occupying up to one-half of the femoral head diameter and
involving between one-third and two-thirds of the weightbearing surface
are likely to collapse in about 30 per cent of cases; and
(3) lesions occupying more than one-quarter of the femoral head diameter
and involving more than two-thirds of the weight-bearing surface will
collapse within 3 years in over 70 per cent of case




3. Bone scintigraphy:
Bone scintigraphy with
99m
Tc-methylenediphosphonate, shows high sensitivity for
early detection since the radionuclide activity reflects osteoblastic activity and
blood flow which are absent in AVN.
For symptomatic disease the method is able to provide positive findings in 23
days after the onset of symptoms (cold within hot) and later hot
lesion reflecting revascularization.
In addition, bone scintigraphy suffers from important limitations such as radiation
dose, poor spatial resolution, inability to accurately discriminate the lesion from
other disorders and inability to quantify the lesion.
Single proton emission CT(SPECT) bone scintigraphy offers more diagnostic
accuracy over simple bone scintigraphy.

University of Pennsylvania system for staging of Avascular Necrosis of
femoral head
(Steinberg et al):
Stage Criteria
0 Normal xray / bone scan/MRI
1 Normal x ray but abnormal bone
scan/MRI
2 Cystic & sclerotic changes in the
femoral head
3 Subchondral fracture(crescent sign)
without flattening of femoral head
4 Flattening of femoral head
5 Joint narrowing & or acetabular
changes
6 Advanced degenerative changes


Each stage is divided into 3 grades as:
Mild(<15% of articular surface)
Moderate(15-30% of articular surface)
Severe(> 30% of articular surface involvement)


In addition joint depression is added to the 4
th
stage
IV A < 2mm depression
IV B 2-4mm joint depression
IV C >4mm joint depression.


TREATMENT
Treatment options:
1. Conservative/non surgical treatment
2. Core decompression
3. Core decompression+ bone grafting
4. Osteotomy
5. Joint replacement

Conservative:
Generally for stage 0(for preserving opposite hip)
Restricted weight bearing: No benefit
Drugs(indeterminate benefit):
Statins:
Stimulate the differentiation of marrow pluripotent cells into osteogenic
cells than fat cells( opposite effect is seen with corticosteroids).
Bisphosphonates:
Bisphosphonates inhibit osteoclastic resorption especially during the
revascularization phase.
Anticoagulants(tPa inhibitors) & enoxaparin
Anabolic steroids(Stanozolol)
Hyperbaric oxygen

Core decompression:
This procedure aims at removing the necrotic bone, decreases the intraosseous
pressure caused by venous congestion & thereby blood ow to prevent further
ischaemic episodes.
Review of the literature currently supports the use of core decompression for the
treatment of Ficat stage I and IIA small central lesions in young, nonobese
patients who are not taking steroids.
For more advanced Ficat stages (IIB or III), the results of core decompression are
much less predictable.





Procedure(Hungerford):
Patient in supine/lateral decibitus position, mid lateral incision centered
over the subtrchanteric area
3.2 mm guide wire is passed just through the lateral cortex just proximal to
the lesser trorochanter
( risk of stress fractures if passed distal to it)
Direct the tip of the guide pin to the center of the diseased portion of the
bone.
Overream the guide pin with an 8-mm reamer.
Skin closed in layers
Post op: Partial weight bearing (50%) on crutches is continued for at least 6
weeks to protect the cortical window

Core decompression along with bone grafting:
The procedure provides decompression of the osteonecrotic lesion, removal of
the necrotic bone, and structural support and scaffolding for repair and
remodeling of subchondral bone.
Bone grafting can be cortical, cancellous & vascularised fibular bone graft


Cortical strut-grafting(Phemister):
This technique involves the removal of an 8 to 10mm diameter cylindrical core of
bone from the femoral head and neck. This core tract is then filled with cortical
strut grafts harvested from the ilium, fibula, or tibia.
Postoperatively, protected weight-bearing is used for 3-6 months.

Cancellous bone grafting:
Lightbulb procedure (Rosenwasser et al):
In this procedure, the cortical window is lifted from the femoral head neck
junction . Cancellous bone graft from the iliac crest is used to fill the defect in the
femoral head after complete evacuation of the necrotic bone.
Trapdoor procedure:
Trapdoor is made through the articular cartilage of the femoral head.
Intraoperatively, the femoral head is dislocated and the collapsed segment is
exposed. An approximately 2cm flap is elevated from the chondral surface with
use of scalpels and osteotomes. The necrotic bone is then removed from the
femoral head with curets and burrs until viable bone is reached. This void can
then be filled with bone garfts.

Vascularised bone grafting:
1. Muscle pedicle graft(Meyers et al):
Qudartus femoris muscle graft is utilized

A: Outline for the osseous portion of the graft & the capsular incision
B: Incised & retracted capsule to expose the channel extending to the subchondral infracted
area.
This channel is initially filled with cancellous bone graft over which the bone that is attached to
quadratus femoris is placed.



Rationale:
The necrotic lesion will be replaced by the cancellous graft & blood supply in the
muscle pedicle will replace the necrotic tissue.

2. Core decompression + Vascularised fibular bone graft(Urbaink et al):


Preparation of the hip and harvest of the vascularized fibular graft are done
simultaneously by separate teams
With use of fluoroscopy, a core (16 to 19 mm) is made just distal to the vastus ridge and
precisely into the necrotic area of the femoral head.
Most of the necrotic bone is removed and is replaced with autogenous fresh cancellous
bone from the greater trochanteric area.
Harvest a segment of the ipsilateral fibula, approximately 13 cm long, with as long a
pedicle of peroneal artery and vein as can be obtained. Leave at least 10 cm of the fibula
proximal to the ankle mortise and 10 cm distal to the knee joint unharvested
The fibula with its peroneal artery and two veins is inserted into the core to within 3 to
5 mm of the subchondral area and is stabilized with a 0.62-mm Kirschner wire.
With use of microvascular surgical techniques, the ascending branches of the lateral
femoral circumflex artery and vein are anastomosed to the peroneal vessels of the
fibula.
Osteotomies:
Rationale for performing an osteotomy is based on the biomechanical effect of
removing the necrotic or collapsing segment of the femoral head from the
principal weight-bearing area of the hip joint. This area is replaced with a segment
of articular cartilage of the femoral head that is supported by healthy, viable
bone.

Selection criteria:
(1) an age of less than forty-five years and a painful hip;
(2) an early post-collapse or late pre-collapse status of the hip, with no
narrowing of the joint space or acetabular involvement;
(3) a small-to-medium lesion (a combined necrotic angle of 200); and
(4) no chronic use of high doses of corticosteroids.

Transtrochanteric Rotational Osteotomy(Sugioka):
The rationale of the procedure is to reposition the necrotic anterosuperior
part of the femoral head to a non weight bearing locale.
The femoral head and neck segment is rotated anteriorly around its
longitudinal axis so that the weight bearing force is transmitted to what
was previously the posterior articular surface of the femoral head, which is
not involved in the ischemic process.
Merle D Aubgine curved varus osteotomy, Mc murray varus displacement &
pauwels varus angulation osteotomy have also been described with varying
success rates.

Resurfacing hemiarthroplasty:
Limited femoral resurfacing or hemi-resurfacing arthroplasty is a viable option in
young patients with either an extensive pre-collapse lesion or a post-collapse
lesion without acetabular involvement. This procedure offers several advantages:
(1) the damaged cartilage on the femoral head is removed,
(2) femoral head and neck bone stock is preserved, and
(3) revision to a subsequent total hip arthroplasty is not complicated
When there is moderate-to-severe involvement of the femoral head, a total hip
arthroplasty may be the only alternative.

Total articular resurfacing arthroplasty(TARA):
Here articulating surface of the femoral head with a metal component
while resurfacing the articulating surface of the acetabulum with a thin
plastic shell inserted with cement.
Because of the high failure rates on the acetabular side, this prosthesis is no
longer used.
The use of femoral cap without the acetabular resurfacing eliminates
failure secondary to polyethylene wear or loosening of the acetabular
component.
Limitation:
Revision of the TARA device to a total hip arthroplasty was difficult because
of the osteolysis caused by the particulate debris generated by wear of the
polyethylene acetabular component. However, with the use of a femoral
head component as a hemiresurfacing device, osteolysis is no longer an
issue. The operative procedure of converting a hemiresurfacing
arthroplasty to a total hip arthroplasty is similar in difficulty to a primary
total hip arthroplasty.
Limited pain relief when compared to THR.

Indications:
1. Young patients with no or minimal degeneration of the acetabular cartilage
presenting with either a crescent sign or collapse of
the femoral head
2. Young patients without femoral head collapse but with extensive
osteonecrotic involvement of the femoral head (a combined necrotic angle
of >200 or femoral head involvement of >50%).

THR:
Indications:
(1) Osteonecrosis of the femoral head & associated advanced secondary
degenerative arthritis
(2) an older or low-demand patient with extensive involvement or collapse of the
femoral head as well as sufficient symptoms to justify total hip arthroplasty.

Contraindications:
(1) young patients with early-stage osteonecrosis of the femoral head for whom
treatment options that save the femoral head are available
(2) Patients at excessively high risk for complications of total hip arthroplasty
(for example, those with severe ongoing ethanol abuse who might be at excessive
risk for dislocation of a total hip pros-thesis).

A young, active, healthy patient with good bone might be considered a good
candidate for an uncemented implant and an alternative bearing surface,
whereas an older, sicker patient with poor bone stock might be better treated
with hybrid or cement fixation.
Poor prognostic factors include: AVN secondary to Ethanol abuse, long term
steroid usage, sickle cell anaemia SLE (Idiopathic AVN has good results when
treated with THR).
Given the young age of most patients affected with this disease, if total joint
replacement is elected, the patient should be well informed of the almost certain
need for one or more revision hip replacements later in life



Treatment Protocol



References:
1. Campbells operative orthopaedics: 12
th
edition: Pg 358-366.
2. The Journal of Bone & Joint Surgery: VOL 77-A NO. 3: MARCH 1995: Non-
Traumatic Avascular Necrosis of the Femoral Head MARCH 1995: M.A
Mont & D.S Hungerford.
3. The Journal of Bone & Joint Surgery Volume 84-a number5 may2002:
Osteonecrosis of the hip: management in the twenty-first century
4. Turek 6
th
edition Pg: 1198-1202

Stages Treatment
Ficat I & IIA
Shimizu grade1
Steinert 0-II
Core decompression +/- bone grafting
Ficat IIB & III
Shimizu grade II
Steinert III & IV
Age: <45:
Core decompression with or without bone
grafting
Osteotomies
Age: >45: Limited hemisurface replacement/ THR
Ficat III & IV
Shimizu grade III
Steinberg V & VI
THR is a better option.