 Cellular death of bone components following interruption of blood

supply.

 Synonyms:
 Ischemic necrosis of the bone.
 Osteonecrosis.
 Aseptic necrosis of bone.
 Long recognized as a complication of femoral
neck fractures.
 Also recognized in alcoholics and corticosteroid
drug users.
 Today, it is recognized in a number of clinical
conditions apart from trauma.
 Femoral condyle

Femoral head

Head of humerus
Capitulum

Scaphoid

Talus
 Traumatic
 Due to severence of blood supply of a portion of
the bone.
 Head of femur is the most notorious.
 Other known sites: proximal scaphoid, proximal
talus and lunate.
 Non-traumatic
 Infection.
 Hemoglobinopathy (e.g. Sickle cell disease)
 Storage disorders (Gaucher’s)
 Caisson’s disease
 Coagulation disorders
 Drugs:
 Corticosteroids
 Bisphosphonates
 Others
 SLE
 Alcohol abuse
 Pregnancy
 Ionizing radiation
 Idiopathic
Subchondral bone –
 Lie in the most distant vascular territory.
 Sustained largely by end arterioles with limited collaterals.

Vascular sinusoids
 Share a rigid compartment with the marrow components - one can expand only at the
expense of the other. May also be involved in vasospasm, thrombosis, fatty embolism,
etc.

Extra-medullary blood supply:

 May be influenced by various factors such as external pressure (raised intracapsular
pressure in neck of femur); kinking; intravascular obstruction (plaques / thrombus /
emboli / arterial diseases) or total disruption (rupture).
 Mechanical disruption of the blood supply of vulnerable regions directly
responsible for ischemia and infarction of bone cells.

The proximal talus

Proximal scaphoid

The most infamous – head of

femur
Rarely, impacted injuries of osteoarticular surfaces separate a crescent of
subchondral bone that render it avascular.
 Role of intra-vascular thrombosis  Role of extravascular marrow swelling
 Corticosteroid +/- alcohol abuse  80%  Increase in marrow fat, as mediated by
 Thrombophilia & hypofibrinolysis. corticosteroid administration / alcohol
 Coagolopathies (e.g. pregnancy, SLE – abuse / etc 
antiphospholipid deficiency, sickle cell  Sinusoidal compression
disease).  Venous stasis
 Retrograde ischemia
 Role of hyperlipidemia & fat embolism
( Jones et al)
 Capillary endothelial damage
 Platelet aggregation
 Thrombosis
 Asymptomatic during the earliest stages of bone death. Discovered
incidentally on x-rays.

 PAIN – most common presenting feature.

 Swelling – especially in subcutaneous sites like knee.

 Joint clicks – due to loose fragments in the joint.

 Deformity & stiffness – late findings (e.g. limp, limitation of movements,

etc)
 Tenderness around affected joint.
 Restriction of one or more movements depending upon site of the lesion.
 Muscle wasting and deformity.
 Secondary features e.g. ulnar nerve palsy in capitulum osteonecrosis.
 Death of bone does NOT alter the appearance in x-rays.

 Appearance in x-rays is due to

1. Revascularization.
2. New bone formation (“sclerosis”)
3. Fracture and collapse of the dead bone.
4. Secondary degenerative changes, especially in weight-bearing joints.

 X-ray changes are NOT apparent till at least 3 months after the actual event.
 Crescent sign – x-ray
appearance in AVN

Sclerosis & cystic changes

Joint space narrowing and

acetabular involvement
Flattening and fragmentation of femoral
head
Radio-scintigraphy (Tc-99–sulfur colloid)
- Cold areas  avascular / post-traumatic segments /
significant cut-off of blood supply. This denotes a
very early stage

- Hot areas  more commonly seen. Denotes

hyperemia and new bone formation around the
infarct.

- No relation between scintigraphic appearance

and pain & hip function once symptoms have
appeared.
MRI
- Most sensitive non-invasive investigation to detect
early osteonecrosis.

- Useful not only in detection, but also follow up of

disease and efficacy of treatment.

- MRI of pelvis is mandatory when one hip shows

features of AVN – since early detection of
contralateral hip involvement is possible.
Canula inserted into metaphysis, pressure measured at rest and after rapid injection of
saline.

Normal resting pressure in marrow sinusoids – 10-20 mm Hg.

Rises by about 15 mm Hg on rapid injection of saline.

In osteonecrosis, both resting pressure and response to saline injection rise 3-4 fold.

Phenomenon most readily demonstrated in proximal femur.

 Osteoporosis.

 Osteoarthritis.

 Bone marrow edema syndrome (transient osteoporosis).

 Osteonecrosis of femoral head occurring in childhood.
 Age group: 4 – 8 years.
 Passes through three stages:
1. Ischemia and bone death.
2. Revascularization and repair.
3. Distortion and remodelling.

 Differentiate from:
 Slipped capital epiphyses.
 Tuberculous synovitis.
 Juvenile chronic arthritis / ankylosing spondylitis.
Modified from Ficat & Arlet
Goal of treatment – stable, pain-free joint.

Conservative.
 Limiting weight bearing.
 Pain relief with NSAIDs / analgesics. Pain management is mainstay treatment in advanced cases where further treatment is not
feasible / affordable.
 Modification of activities.

Surgical
 Core decompression
 Bone graft
 Osteotomies
 Arthroplasty
Core decompression

Believed to relieve intraosseous pressure.

Most effective when performed BEFORE necrosis

is complete – hence suited for FICAT stage I and
IIa only.

Not effective beyond stage IIb (lennox et al – 100%

good results with stage I, 29% with stage IIa and
0% with stage II b.
Bone graft

Best results obtained with free vascularized bone graft.

Indicated for stage II and beyond
Advantages over THA:
1. Possibility of retaining a live femoral head – more activity and longer life.
2. Avoiding complications with a foreign body head.
3. Possibility of THA if this procedure fails.
 Disadvantages:
1. Longer period of recovery.
2. Less complete pain relief.
3. Variable success rate.
4. Not effective in advanced disease (after arthritis of the joint supervenes)
 Rationale based on four aspects of management:
1. Decompression of femoral head.
2. Excision of sequestrum
3. Filling the defect with osteo-inductive cancellous graft supported
with a cortical strut.
4. Protecting the construct with limited weight-bearing till it heals.
Osteotomies of proximal femur

 Based on the idea that collapse of the femoral head

invariably involves the weight-bearing region,
sparing the non-weight bearing regions.

 Suitable only when the involved segment is small

to medium (less than 30% of surface) – (FICAT
stage II or III).

 Usually performed in young patients “to buy time”

so that a total hip arthroplasty may be delayed as far
as possible.
Trans-trochanteric osteotomies

- Valgus
- Varus.
- Flexion
- Extension

Pre-operative x-rays made with hip in maximal abduction and

adduction, and femoral fit in the two conditions studied.

If the involved segment is brought away from the weight-bearing

axis in abduction, a varus osteotomy is performed.

If in adduction, a valgus osteotomy performed.

Transtrochanteric rotational
osteotomy (SUGIOKA)

 Described first in 1978

 Head and neck of femur rotated along its longitudinal

axis such that posterior(uninvolved) portion comes to
bear weight.

 Best suited only when area of necrosis is less than 30%

of articular surface.

 Sugioka emphasized evaluation of posterior surface of

femoral head in lateral view with hip in 90` flexion, 45`
abduction and neutral rotation  intact area should be at
least one third the total articular surface.
Arthroplasty

When all else fails, replace the joint!

Preferred method in joints requiring both stability and mobility

e.g. Hip, Knee, Shoulder(gleno-humeral).

Total hip arthroplasty  gold standard treatment for terminal lesions of

avn femur. Hemiarthroplasty has shown uniformly poor results in
the long run

Since life of an implant is limited (~ 15-20 years), the procedure should

be delayed as far as possible in younger patients.
Arthrodesis

Most suited where

 Structural damage and distortion of joint preclude

conservative measures.

 Mobility is sacrificed without severe loss of function e.g.

ankle, wrist.
 Use corticosteroids with caution; and in minimal effective dose.
 Abstinence from alcohol, esp. those receiving steroids or having other risk factors (e.g. sickle cell disease).
 Care in preventing hypoxia / anoxia in patients with sickle cell disease.
 In cases of traumatic displaced / angulated fractures or dislocation, urgent reduction / fixation (ideally within 6
hrs).
 Meticulous adherence to decompression procedures in deep sea divers / compressed air workers.