Update in

Osteonecrosis of
Femoral Head
Scope
 Definition
 Etiology
 Pathogenesis
 Diagnosis
 Treatment
Definition
 Disease of impaired osseous
blood flow in which a
circumscribed area of bone
becomes necrosis
Etiology
 Traumatic
 Non-traumatic
Etiology (Non-traumatic)
 Steroid usage
 Alcohol
 Blood disease
 Sickle cell anemia
 Hypofibrinolysis
 Caisson disease
 Connective tissue disease
 Idiopathic 15-20%
Etiology
 Steroid usage
 SLE incidence 15-44%

 Oinuma K.

คนไข้ SLE 72 ราย high dose (>30mg/d)

พบ AVN 44% ใน 3 เดือน

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.
Etiology
 Steroid usage
- 6-8 years (range 1-19)
- Kidney transplant AVN 4.5%
- 80% Bilateral
Etiology
 Koo KH, et al
 ผู้ป่วย 22รายเกิด AVN

 เฉลี่ย 5928 mg(1,800-15,505 mg)

 Average 5.3 m.(1-16 m)

 21/22 รายเป็นใน 1 ปีแรก

Risk period for developing osteonecrosis of the femoral head in

patients on steroid treatment. Clin Rheumatol 2002 Aug:21(4):299-3
Steroid usage
 Pathophysiology:
1)Direct cellular toxicity
2)Abnormal fat metabolism
-Adipocyte hypertrophy
-Fat embolism
Etiology
 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
 Etiology
 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
Pathogenesis
 Infarction theory
 Fat embolism theory
 Accumulative cell stress theory
 Progressive ischemia theory
 Immunologic reaction
Diagnosis
 History
 Physical examination
 Laboratory test
 CBC, ESR R/O infection
 Cortisol level
 Radiological examination
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 examination
 Pain on internal rotation
 Decrease ROM
 Hip abductor weakness (G.
medius)
 Shortening of limb
Plain film X-
ray

 AP pelvis, frog
leg
 Crescent sign
 Secondary OA
change
 Technetium bone scan (Tc
99)
 Preradiographic phase AVN
 Decrease uptake

 Sensitivity and specificity <

MRI
 SPECT

(Single-photon emission
computed tomography)
sensitivity 100% in renal
transplant pt.
BONE 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)

  Investigation of choice
MRI  Decrease signal
 Screening  T1 coronal
scan
 CT scan
 Arthroscopic examination
 Ficat’s staging
Clinical Plain MRI
film
Stage O No pain normal
abnormal
Stage I pain normal +
Stage II + crescent’si +
gn
Stage III + Collapsed +
femoral
head
Narrow
Stage IV + joint +
space+acetab
ulum
normal sclerotic
Crescent sign Collapse
 Acetabular Severe joint
involvement destruction
Treatment
 Conservative
 Temporally non-weight
bearing
 Electrical stimuli
 Surgery
 Joint preserving

procedure
 prosthetic replacement
 Treatment
 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 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 procedure
 Core decompression
 Osteotomy
 Free vascularized fibular/ iliac
graft
 Arthrodesis
 Arthroscopic debridement
(+core)
Treatment
 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 Decompression
 Result of core
decompression
 133 AVN, stage I+II, F/U 9.5 years
90% successful clinical result
79% no radiographic progression
(Ficat. JBJS;67B:3-9:1985)
 204 AVN, F/U 3 years
no additional operative Rx was necessary
96% stage I
77% stage II
60% stage III
(Zizic and Hungerford. Textbook of Rheumatology Ed 2,
Vol.2:1689-1710)
Electrical 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
Osteotomy
 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 Osteotomy
 Candidate
 < 40 years old

 Small lesion (< 200

degrees)
 Mobile hip

 No longer taking steroid

 Difficulty for THR

 Removal of implants after

union
 Result of Ostetomy
 Sugioka Y (CORR.
1984)
1984
 158 hip (113 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
10-17 ปี มี3 ราย> THR
ถ้า Collapse < 2 mm
จะได้ผล ดีที่ 15 ปี
 Treatment
 Vascularized bone graft
- fibular, iliac crest
- revascularized
Vascularized 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 graft
 Disadvantage:
 Technical demand

 A few centers have significant

experience with this technique
 Well-trained microvascular surgeon

 More complication
 Vascularized bone graft
 Advantage: The result is better than
core
decompression in stage II,
III
(Ficat classification)
Result of Vascularized bone
graft
 Urbaniak JR (JBJS. 77-A.1995)
 mean survival rate= 88% ในผู้ป่วย

stage I , II
 Judet H (CORR.2001) FU 18 ปี
 พบว่า 80% ของผู้ป่วย 60 ราย stage I,II

ยังได้ผลดีอยู่
Prosthetic replacement
surgery
 Limited resurfacing
arthroplasty
 Resurfacing arthroplasty
 Hemiarthroplasty
 Total hip replacement
Limited Resurfacing
Arthroplasty
 Result of Limited Resurfacing
Arthroplasty
 Mont MA (CORR.2001, J. Arthroplasty
2001.)
 ผู้ป่วย 30 รายใน stage III, IV เปรียบเทียบกับผู้ป่วยอีก

30 ราย ใน stage เดียวกัน แต่ใช้วิธกี ารเปลี่ยนทั้งข้อ

 FU 7 ปี พบว่า 90% และ 93% ของทั้ง 2 วิธี

ยังคงใช้ได้ดีอยู่
 Siguier T (CORR.2001)
 ผู้ป่วยstage III 26 ข้อ และ stage IV 10 ข้อ
Hemisurface arthroplasty
Hemisurface or partial
resurfacing 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)
 Hemiarthroplas
ty
 Chan YS
(CORR.2000)
 ได้เปรียบเทียบผลการรักษาโดยใ

ช้ Bipolar กับ THR

ในคนไข้คนเดียวกันพบว่า 24
ใน 28 ข้างของ
bipolar และใน 23 ใน
28 ข้างของ THR
ได้ผลเป็นที่พอใจเมือ่ ติดตามผลไ
ปเฉลี่ย 6.4 ปี
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
 Rx. 1. Conservative
2. Core decompression
Ficat stage II 3. Others
Ficat stage Rx. 1. Conservative
2. Hemiarthroplasty
III 3. Others
Ficat stage Rx. 1. Conservative
IV 2. THR
3. Arthrodesis
Thank You