PowerPoint Presentation

[Audio] Good morning everyone, We are here today to discuss an important topic in the field of orthopedics: Avascular Necrosis of Femoral Head. We will be looking at its risk factors, incidence, demographics and pathophysiology, as well as any associated conditions with traumatic injuries. Let us begin..

[Audio] Avascular necrosis of the femoral head is a serious joint condition in which the femoral head loses its blood supply, resulting in death of the bone and subsequent collapse. Unattended, it can cause a major decrease in joint stability and range of motion. Risk factors include trauma, alcohol use, drugs, systemic diseases and genetic predispositions. Diagnosed and treated early, the patient's joint stability and range of motion can be restored..

[Audio] Avascular necrosis of the femoral head occurs when the bone tissue dies due to insufficient blood supply. The majority of the blood supply to the head of the femur is provided by the medial and lateral circumflex branches of the profunda femoris artery which is a branch of the femoral artery. Such delicate blood supply structure makes the head of the femur especially vulnerable to any damage that can affect the blood supply and lead to avascular necrosis. Thus, it is essential to be aware of the risk factors which can cause it, such as alcohol and corticosteroids abuse..

[Audio] Approximately 20000 people in the United States are impacted by Avascular Necrosis of the Femoral Head annually. This medical issue most commonly occurs in individuals aged between 35 to 50, and male individuals are more prone to it than female individuals. It is generally observed to be bilateral in both hips 80% of the time. Moreover, about 3% of those affected by Avascular Necrosis have involvement of multiple joints..

[Audio] Avascular Necrosis is a condition caused by a restricted blood supply leading to death of tissues in the femoral head. Causes of Avascular Necrosis can be divided into radiation trauma, hematologic diseases, dysbaric disorders, marrow-replacing diseases and sickle cell disease. If left unmanaged, these conditions can cause disruption in delivery of oxygen and nutrients to the femoral head, as well as impaired waste removal leading to cell and tissue death. Treatment includes medications and therapies targeted to reduce the cause of the condition and prevent progression of the disease..

[Audio] Indirect causes of avascular necrosis of femoral head can include alcoholism, hypercoagulable states, steroids, systemic lupus erythematosus, viruses such as cytomegalovirus, hepatitis, HIV, rubella, rubeola or varicella, as well as certain protease inhibitors, which are a type of HIV medication, and idiopathic cases..

[Audio] Idiopathic Avascular Necrosis is a medical condition where interruption of the blood supply to the femoral head occurs. This condition is characterized by a final common idiopathic pathway which includes intravascular coagulation, venous thrombosis, retrograde arterial occlusion, intraosseous hypertension, and decreased blood flow to the femoral head, with Avascular Necrosis of the femoral head and chondral fracture and collapse as the ultimate result..

[Audio] Avascular Necrosis of the Femoral Head is a condition wherein the blood supply to the femoral head is disrupted as a result of trauma. When this happens, the bone tissue can be damaged or destroyed, causing pain, swelling, and decreased range of motion in the affected area. Early diagnosis and treatment is key to preventing long-term complications..

[Audio] AVN, or Avascular Necrosis, is a condition where the bone tissue in the femoral head dies due to reduced blood supply. Though traumatic injuries can increase the risk, the likelihood varies depending on the type of fracture. Femoral head fractures, for example, have a 75 to 100 percent chance of developing AVN, while basicervical fractures have a 50 percent chance and cervicotrochanteric fractures have a 25 percent chance. Hip dislocations, if reduced within 6 hours of injury, have a 2 to 10 percent chance, while intra-trochanteric fractures are relatively rare. The greater the initial displacement and poorer reduction of the fracture, the higher the risk of AVN, while quicker action to reduce the fracture may also reduce the risk..

[Audio] The Ficat and Arlet Classification of Avascular Necrosis of Femoral Head distinguishes between four stages. Stage 0 is preclinical, detectable only by imaging or on the opposite hip. Stage 1 shows no visible changes on x-ray scans, though MRI and bone scintigraphy may reveal early changes. Stage 2 has reactive changes in the subchondral area with no structural damage or distortion of bone. Stage 3 is the early collapse of the femoral head, involving structural damage and distortion of the bone..

[Audio] At stage four, the articular surface collapses and the initial signs of secondary osteoarthritis appear. Treatment at this point concentrates on controlling and managing pain and preserving as much of the joint as feasible. In addition to patient education and exercises, this can help the patient maintain their quality of life..

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[Audio] ARCO staging system categorizes avascular necrosis of the femoral head into six stages. Stage 0 is when the person is unaware they have the condition and all related tests come back normal. Stage 1 biopsy displays osteonecrosis while X-ray or radio-nuclide scans in Stage 2 may show osteonecrosis. Stage 3 X-rays and Magnetic Resonance Imaging (MRI) may produce the initial signs of osteonecrosis and is subcategorized based on the area of the articular surface. Stage 4 X-rays give a 'crescent sign' yet the femoral head remains spherical. Stage 5 reveals flattening or collapse of the femoral head with subcategorization based upon the length of the 'crescent' or articular surface. Lastly, Stage 6 consists of the changes identified in the other stages with a noticeable destruction of the articular surfaces..

[Audio] I will be discussing avascular necrosis of the femoral head, which typically presents with insidious onset of pain, pain with stairs, inclines, and impact pain. Initially physical exam findings may be normal but as the condition advances, it may begin to show the same symptoms as hip osteoarthritis, including limited motion, particularly in regards to internal rotation..

[Audio] Radiological studies are an important requirement for diagnosing avascular necrosis of the femoral head. Plain radiographs should be taken, including AP hip, frog-lateral of the hip, AP and lateral of the contralateral hip. This helps to distinguish the condition and its seriousness. Additionally, MRI and CT scans may be needed for a complete diagnosis..

[Audio] MRI is by far the most reliable form of imaging for diagnosing avascular necrosis of the femoral head. It is characterized by a double density with a dark, low intensity band on T1 images and focal brightness on T2, which indicates bone marrow edema. Even if the radiographs are negative, they should still be requested in cases of suspected avascular necrosis. Moreover, MRI is also useful for predicting future pain and progression of the disease, due to the presence of bone marrow edema..

[Audio] A CT scan can be useful in diagnosing Avascular Necrosis of the Femoral Head. Although it may not be the most exact way to determine the condition, it does display the area of bone damage which can be advantageous when figuring out a surgical plan..

[Audio] Bone Scintigraphy is a highly sensitive imaging technique with accuracy rates of up to 85% used to detect and track Avascular Necrosis of the Femoral Head, particularly when multiple sites are affected. Results can vary depending on when the scan is taken. An early scan may reveal a cold area, likely associated with a vascular interruption, while a later scan may show the so-called "doughnut sign", which is a cold spot surrounded by a high uptake ring..

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[Audio] Intramedullary pressure within the femoral head is an important factor in diagnosing avascular necrosis. In the early phases of ischemic necrosis, intra-medullary pressure is normally high. An accurate measurement of pressure can be taken at rest, and after the swift injection of saline, by putting a cannula in the metaphysis. The typical resting pressure is 10-20mmHg, and will likely raise by approximately 15mm after the saline injection. Remarkably, similar results have also been recorded in Osteoarthritis, though the changes are dramatically less significant than those observed in Osteonecrosis..

[Audio] Bisphosphonates can be used as nonoperative treatment for avascular necrosis of the femoral head, with some studies indicating that it may prevent a femoral head from collapsing in cases of precollapse avascular necrosis. However, other studies have failed to demonstrate any benefit of using bisphosphonates to prevent collapse..

[Audio] Core decompression, with or without bone grafting, is a procedure used to treat avascular necrosis of the femoral head. The aim is to reduce intraosseous pressure, reduce pain, and encourage healing. The traditional core decompression technique involves drilling an 8-10 mm hole through the subchondral necrosis whereas an alternative approach is to insert a 3.2 mm pin into the lesion two to three times. Bone grafting can also be used to promote healing. Both traditional and alternative core decompression procedures are recommended in early AVN cases, before subchondral collapse has occurred due to a reversible cause..

[Audio] The goal of this presentation is to discuss the indications, strategy, and outcomes of a surgical procedure to address avascular necrosis of the femoral head. In general, the technique is used for small lesions, less than 15%, which can be rotated away from a weight bearing surface. This technique is typically performed through the intertrochanteric region with either a varus rotational osteotomy or valgus flexion osteotomy. The reported success rate ranges from 60 to 90%, mainly in Japan. However, the procedure can distort the femoral head, making a total hip arthroplasty more difficult. Therefore, careful consideration is required when deciding to pursue this procedure..

[Audio] The Mont trapdoor technique, or the more recently developed Merle D'Aubigne lightbulb technique, is an effective surgical intervention for avascular necrosis of the femoral head. The goal of the procedures is to gain access to the necrotic area of the femoral head and to place bone grafts in order to stimulate revascularization. The decision whether to use the Mont trapdoor technique or the Merle D'Aubigne lightbulb technique is based on the stage of the disease, with preference being given to procedures used before the collapse of the femoral head..

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[Audio] For young patients with AVN of the femoral head, vascularized free-fibula transfer is a viable treatment option. This technique involves removing the necrotic area with a large core hole and placing a fibular strut under the subchondral bone. This can help prevent collapse or tamp up small areas of collapse. This procedure is especially helpful when the etiology of the AVN is reversible..

[Audio] The objective of treating avascular necrosis of the femoral head is to prevent further bone destruction and provide a stable hip joint with minimal pain. However, outcomes for patients over 40 are less predictable, although some studies show up to 80% success at five to ten years follow-up. Possible complications related to the donor site may include sensory deficit, motor weakness, FHL contracture, and tibial stress fracture based on the side from which the graft was taken..

[Audio] DJD is a common condition that can affect the hip joint. In more advanced cases, with a collapsed femoral head, a total hip replacement may be necessary. Preparing the femur must be done with extra care to decrease the risk of perforation in the femoral canal. In conclusion, total hip replacement is a viable choice for people experiencing a severe form of DJD..

[Audio] I have demonstrated how total hip arthroplasty can be an effective treatment for avascular necrosis of femoral head. This type of surgery offers a higher rate of linear wear of the polyethylene liner, a higher rate of osteolysis, good pain relief and immediate return of function, particularly when performed on younger patients. It is the best and most reliable means to manage such cases..

[Audio] Total hip resurfacing is a potential treatment choice for progressed degenerative joint inflammation with an isolated concentration of avascular necrosis. Nonetheless, this system ought to be stayed away from in patients with hidden illness forms, continuous steroid utilization, or renal ailment as these can cause lacking bone quality or expanded metal particle introduction from metal-on-metal segments. Medium-term follow-up of this method has recognized potential issues with acetabular disintegration and torment in certain patients. It is significant cautiously survey each patient before deciding if total hip resurfacing is a suitable treatment..

[Audio] Avascular Necrosis of the Femoral Head is a condition in which the blood supply to the hip joint is blocked, resulting in a gradual deterioration of the cartilage in the hip joint and eventually the femoral head. To treat the condition, resurfacing the hip joint is necessary, replacing the damaged cartilage with an artificial prosthesis. This procedure helps to maintain the patient's mobility and reduce any long-term pain related to the condition..

[Audio] Hip arthrodesis is an option for young patients who are in labor-intensive occupations. In this procedure, the hip joint is fused and replaced with a prosthetic. This can help reduce the pain and disability caused by avascular necrosis of the femoral head. Before deciding to undergo this type of treatment, it is essential to consult with a qualified orthopedic specialist..

[Audio] Necrotic femoral head collapse is a major contributing factor to the development of osteonecrosis of the femoral head. The risk of collapse is based on the modified Kerboul Combined Necrotic Angle, which is calculated by adding the arc of the femoral head necrosis on a mid-sagittal and mid-coronal magnetic resonance imaging (MRI) image. This angle is a reliable indicator of the risk of femoral head collapse, and can help guide treatment decisions for patients with osteonecrosis of the femoral head." The modified Kerboul Combined Necrotic Angle is an important tool in assessing the risk of femoral head collapse for people with osteonecrosis of the femoral head. By combining a mid-sagittal and mid-coronal MRI image, the arc of the femoral head necrosis can be added together, yielding an accurate measure of the risk of collapse. This angle is a reliable indicator to help guide the treatment decisions for those suffering from this condition..

[Audio] Recent studies on Avascular Necrosis of Femoral Head show that the likelihood of necrosis is associated with the combined necrotic angle. A combined angle smaller than 190° defines a low risk group, while a combined angle of 190° to 240° implies a moderate risk group. Any combined angle greater than 240° identifies a high risk group..

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