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Osteonecrosis ofOsteonecrosis ofFemoral HeadFemoral Head

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ScopeScopeDefnitionDefnitionEtiologyEtiologyPathogenesisPathogenesisDiagnosisDiagnosis

Treatment Treatment

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DefnitionDefnitionDisease o impaired osseous blood owin which a circumscribed area o bone

becomes necrosis

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Metatarsal head Freiberg’s Diseasenavicular Kohler's Disease

lunate Kienbock Disease

calcaneum Sever’s DiseaseTibial tuberosity Osgood-Schlatter's

disease

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Etiology ("PLASTIC RAGS"):

Pancreatitis, Perthe’sLu us

AlcoholSteroi!sTrau a, Trans lant

I!io athic, In#ectionC aisson !isease,Collagen $ascular !isease

R a!iation,R heu atoi! arthritis

A yloi!Gaucher !isease Sic%le cell !isease

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EtiologyEtiologyTrau atic

&on'trau atic

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Sic%le cell !iseaseCaisson !iseaseThro ocyto enia

at e olis

Gaucher’s !iseaseTu erculosis

Cortisone*alcohol+ys aric ische ia(caisson)

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Pathogenesis to - onth, the #e oral hea! is su lie! y

(.) eta hyseal $essel / enetrate gro0th !isc (1)lateral e i hyseal $essel' run in retinaculu (2)$essel in liga entu teresThe ete hyseal su ly gra!ually !eclines until, y theage o# - yrs, it has !isa eare!3y age o# 4, $essel in liga entu teres ha$e !e$elo e!53et0een -'4 yrs, #e oral hea! loo! su ly entirely onLE65

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E##usion cause stretching 7 ressure toLE65

&o enough ressure to loc% arterial #lo0 ut cause $enous stasis resulting raise inintraosseous ressure an! su se8uent

ische ia5 (Lin & Ho 1991)

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(.) eta hyseal $essel / enetrate gro0th !isc

(1) lateral e i hyseal $essel' run in retinaculu(2) $essel in liga entu teres

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#NOFDislocation ncidence o osteonecrosis is !!" in undisplace #! $ %" in displaced #Pre&alence a ter dislocation' !%$! "

reduction is delayed by more than ew hours thefgure rise to (%"

)orticosteriods *%mg+day is associated with increased ris,-elati&e ris, goes up ($. old or e&ery !% mg+dayincrease

/lcohol 0(%%ml+wee, increase the relati&e ris, 1$2 old

Sic,le celldisease

' the pre&alence o osteonecrosis is

($*"3 /ge$ dependent ' 44$ %" o patients by age 4

S5E incidence '! $(("'high dose 604%mg+d7 /8N (("de&elops &ery early a ter starting high dosecorticosteroid treatment3 /nnals o -heumaticDiseases3*%%!9.%6!*7'!!( $13

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EtiologyEtiologySteroi! usage

' 9' years (range .'.;) ' ' ?> 3ilateral

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Steroid usageSteroid usagePatho hysiology:

.)+irect cellular to@icity 1)A nor al #at eta olis

'A!i ocyte hy ertro hy

' at e olis

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EtiologyEtiology Marston SB, et al

Soli! organ trans lant (%i!ney li$er)=1 t5A6& #e oral hea! ..> (1?>)A6& in .? onths

BRI screening in the #irst year

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EtiologyEtiology Ferrari P, et al.

o oDygous -G*-G PAI'. genoty e5

Ries MD.I6 in#ection (ris% #actor o# A6&)

/ssociation between human immunodefciency &irus andosteonecrosis o the emoral head3 : /rthroplasty *%%* Feb'!;6*7'!4 $2

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PathogenesisPathogenesisn arction theory

Fat embolism theory

/ccumulati&e cell stress theoryProgressi&e ischemia theoryImmunologic reaction

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Patho hysiology o# sic%lecell !isease

β9 Glu 6al

+eo@y S oly er #or s 0ith lo0

1, !e en!s on g S concentration,lo0 , high te erature, high 1,2'+PG

n!er a $ariety o# circu stances,!i##erent organs are susce ti le:s leen, renal e!ulla ( a illarynecrosis), 7 any other co lications

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GaucherFs !iseasehere!itary !e#iciency o# the enDy eglucocere rosi!ase (also %*s aci! 'glucosi!ase)5glucocere rosi!e accu ulates in the s leen ,li$er, %i!neys , lungs , rain an! one

arro05

http://en.wikipedia.org/wiki/Glucocerebrosidasehttp://en.wikipedia.org/wiki/Spleenhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Human_lunghttp://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/wiki/Human_lunghttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Spleenhttp://en.wikipedia.org/wiki/Glucocerebrosidase

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AEB +H&ABIC PRI&CIPLE I& A6&

(.) arterial insu##iciency e3g3 FON#< dislocation

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(-) intraosseous ca illary ta ona!ee3g3 bone in ectione3g3 ?aucher=s disease

$autosomal recessi&e trait $lac, o en@yme A$glycosidase

$osteonecrosis is due to compression o the

marrow capillaries > sinusoids by mass o large macrophagesstuBed with glycocerebroside3 (Ja e, 1972) e3g3 alcohol > steriod' marrow at cell is

signifcantly increased3 (Solo on) e3g3 )ushing syndrome >

amilial hyperlipidaemia e3g3 cassion

disease' at cell swelling contribute to the ischemic changes3(!ooley & "al#er)

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+iagnosis+iagnosis

istoryPhysical e@a inationLa oratory test

C3C, ESR R* in#ectionCortisol le$el

&o s eci#ic ioche ical ar%er #or high alcohol inta%e ( "$i%e$ea#, larke an# "$i%e'el#)

Ele$ation o# #our o# the #ollo0ing is highly suggesti$easpartate

transaminaseC$glutamyl transpeptidase

serum urate serum triglyceride

Ra!iological e@a ination

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istoryistory

A high in!e@ o# sus icious is essentialAn associate! ris% #actor The ost co on resenting sy to is a!ee ain in the groinE@acer ate! y acti$ity

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Physical e@a inationPhysical e@a ination

Pain on internal rotation +ecrease R B

i a !uctor 0ea%ness (G5 e!ius)Shortening o# li

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Plain #il 'rayPlain #il 'ray

AP el$is, #rog legCrescent signSecon!ary Achange

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Con$entional ra!iogra h o# the right #e ur in the #rog'leg osition o taine! 0ith the atient’s thigh a !ucte! an! #le@e!sho0s su chon!ral area o# hy erlucency (arro0s) in theanterolateral as ect o# the ro@i al #e oral hea!5

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Specimen radiograph o a coronally sectioned emoral head segmentre&eals a subchondral racture 6arrows7< which mani ests as thecrescent sign3 Note the ragmentation and compactiono the subchondral cancellous trabeculae< which wea,ens thearticulating sur ace3

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/nteroposterior radiograph o the le t humeral head

in a patient being treated with high$dosecorticosteroids shows multiple subchondral areas ohyperlucency 6arrowheads7 that are indicati&e ostage /8N3

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echnetium bone scan 6 c echnetium bone scan 6 c

227227

Preradiographic phase /8NDecrease upta,eSensiti&ity and specifcity

-SPE)

6Single$photon emissioncomputed tomography7

sensiti&ity !%%" in renaltransplant pt3

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GONE SPE)GONE SPE)

4* /8N o emoral headSPE) detect 4*+4* $0 !%%" sensiti&ity

- detect *!+4* $0 .." sensiti&ity

6 $e Jo rnal o* + clear e#icine. 2--2 4/(0) 1-- 31-11)

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--n&estigation o choice

Decrease signalScreening ! coronal scan

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) scan) scan

/rthroscopic eHamination/rthroscopic eHamination

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Ficat=s stagingFicat=s staging )linical Plain flm -

Stage O No pain normal abnormal

Stage pain normal I

Stage I crescent=sign I

Stage I )ollapsed

emoralhead

I

Stage 8 I Narrow JointspaceIacetabulum

I

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normalnormal scleroticsclerotic

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Crescent signCrescent sign CollapseCollapse

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Treatment TreatmentConservative

Temporally non-weight

bearingElectrical stimuli

Surgery

:oint preser&ing procedureprosthetic replacement

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reatment reatment

Conservative treatmentstage $

NKG with crutches 6. w,s7analgesicIeHerciseF+L * years 1%" poor result

usso< et al3 -esult o conser&ati&e management o osteonecrosiso the emoral head3 / retrospecti&e re&iew3 lin Or%$o 190 J ne 2-72-93215

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reatment Options/8N< Mip

Non$weight bearing)ore decompression)ore decompression I &asculari@ed fbulargra t

)ore decomp I non$&asculari@ed fbular gra t)ore decompI autologous bone marrow cellsOsteotomy-esur acing arthroplastyGipolar arthroplasty

otal hip arthroplasty

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-esult o nonoperati&e -H-esult o nonoperati&e -H /8N + nonoperati&e -H2*" radiographic progression

1(" arthroplasty< /&3 ime *! months (S%ein6er . lin Or%$o 1909)

! /8N + nonoperati&e -H

!%%" collapse< /&3 ime *4 months (8ra# ay an# orrey. J :r%$ro las%y 199/)

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:oint preser&ing procedure :oint preser&ing procedure

Core decompressionOsteotomyFree vascularized fbular iliacgra!t"rthrodesis/rthroscopic debridement6Icore7

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reatment reatment

Core DecompressionDecrease G P 6bone marrow pressure7

ncrease &enous drainagePromote &ascular ingrowthGone gra t< autologous bone marrow

reatment o choice stage $

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)ore Decompression)ore Decompression

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-esult o core-esult o coredecompressiondecompression

!44 /8N< stage I < F+L 23 years2%" success ul clinical result;2" no radiographic progression (Ficat. JBJS;67B:3-9:1985)

*%( /8N< F+L 4 yearsno additional operati&e -H was necessary

2." stage ;;" stage .%" stage

( Zizic and Hungerf rd. !e"t# $ f %&eu'at ( g *d +, (.+:1689-171 )

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Electrical stimulationElectrical stimulation?oal' Enhance bone ormation and racturehealing

/lone or as an adJunct to other surgicalprocedurePE F 6pulsing electromagnetic felds7

$more eBecti&e than symptomatic -H inprecollapse and minimally collapse

$as eBecti&e as core decompression inprecollapse

$more eBecti&e as core decompression inminimally collapse

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OsteotomyOsteotomy

Shi t the necrotic segment out othe region o maJor weight bearing

and replace it with normal boneand cartilageEarly to intermediate stage that

acetabular cartilage is unaBected

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Femoral OsteotomyFemoral Osteotomy)andidate

(% years old

Small lesion 6 *%% degrees7obile hipNo longer ta,ing steroid

Di culty or M--emo&al o implants a terunion

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-esult o -esult o OstetomyOstetomy

Sugio#a $ %Sugio#a $ % )O--3)O--3&'()&'()*

&+( hip % success rate1.$2 "

6!22* < *2 pts<;2"< a&n F+L !! yrs7

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reatment reatmentVascularized bone graft

$ fbular< iliac crest

$ re&asculari@ed

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8asculari@ed bone gra t8asculari@ed bone gra t

?oal 'Decompress the emoral head

-emo&e necrotic boneFill necrotic de ect with osteoinducti&ecancellous bone gra tSupport subchondral bone with strutgra tEnhance re&asculari@ed process

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Disad&antage ' echnical demand/ ew centers ha&e signifcant

eHperience with this techni ueKell$trained micro&ascular surgeon

ore complication

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/d&antage ' he result is better thancore

decompression in stage <

6Ficat classifcation7

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-esult o 8asculari@ed bone-esult o 8asculari@ed bonegra tgra t

Urbaniak JR (JBJS. 77-A.1995)

mean sur&i&al rate 11"

Patients3 stage < Judet H (CORR.2001) F, &( Qear

Found that 1%" o patients .%3stage I II t wor,s well3

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.rosthetic replacement.rosthetic replacement

surgerysurgery

/imited resur!acingarthroplasty0esur!acing arthroplasty1emiarthroplasty

Total hip replacement

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/imited 0esur!acing/imited 0esur!acing

"rthroplasty"rthroplasty

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Memisur ace arthroplastyMemisur ace arthroplasty

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Memisur ace or partialMemisur ace or partialresur acing arthroplastyresur acing arthroplasty

ime$buying procedure or young andacti&e patient

/de uated bone uality and relati&e normalarticular cartilageGone stoc, preser&ation and intactintramedllary canal

Sur&i&orship 1!" at 3! yearsSur&i&orship .!" at !% years

6/mstut@ M)3 Semin /rthroplasty 92'*.!

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MemiarthroplasMemiarthroplastyty

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reatment

Total ip art roplast! $ emoral head I acetabulum $ stage 8 $ sur&i&orship in young patient is

less than in older patient

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otal Mip /rthroplasty

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otal Mip /rthroplasty

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Ficat Stage I

Rx. 1. Conservativ 2. Core dec

Rx 1 Conservative

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Ficat stage

Rx. 1. Conservative 2. Core deco

3. Others

i Rx 1 Conservative

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Ficat stageIII

Rx. 1. Conservative 2. Hemiarthr

3. Others

Fi

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Ficat stageI2

Rx. 1.Conservative 2.THR 3.Arthrodesis

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han, Qou

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