1) Avascular necrosis (AVN) is the death of bone tissue due to a lack of blood supply. It most commonly affects the hip bone.
2) MRI is the most sensitive imaging method for diagnosing AVN. It can detect early changes in bone marrow signal and the pathognomonic "double line sign" on T2-weighted images.
3) AVN is staged based on radiographic and MRI findings, from Stage 0 showing just marrow edema to Stage 4 where the femoral head has collapsed, requiring joint replacement surgery.
1) Avascular necrosis (AVN) is the death of bone tissue due to a lack of blood supply. It most commonly affects the hip bone.
2) MRI is the most sensitive imaging method for diagnosing AVN. It can detect early changes in bone marrow signal and the pathognomonic "double line sign" on T2-weighted images.
3) AVN is staged based on radiographic and MRI findings, from Stage 0 showing just marrow edema to Stage 4 where the femoral head has collapsed, requiring joint replacement surgery.
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1) Avascular necrosis (AVN) is the death of bone tissue due to a lack of blood supply. It most commonly affects the hip bone.
2) MRI is the most sensitive imaging method for diagnosing AVN. It can detect early changes in bone marrow signal and the pathognomonic "double line sign" on T2-weighted images.
3) AVN is staged based on radiographic and MRI findings, from Stage 0 showing just marrow edema to Stage 4 where the femoral head has collapsed, requiring joint replacement surgery.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online from Scribd
Overview • Avascular necrosis (AVN) is cellular death of the components of bone, including bone marrow, due to impaired blood supply. • AVN occurs in a number of conditions. • AVN usually involves the epiphysis of long bones. – Called bone infarct if in diaphysis or metaphysis • AVN of the hip is the most common encountered in clinical practice. • Early diagnosis and appropriate intervention can delay the need for joint replacement. • Patients on corticosteroids and organ transplant recipients are particularly at risk of developing AVN. Pathophysiology: • AVN is due to blood supply disruption, and it affects bones with single terminal blood supply. – Mechanical interruption of blood supply. – Thrombotic or embolic occlusion of blood vessel. – Injury to vessel wall – Pressure on vessel wall – Mechanism unknown (eg, high dose corticosteroids, alcoholism, primary AVN) Etiology • SLE • Rheumatoid arthritis • Pancreatitis Fracture / dislocation • Gaucher's disease • Steroid use • Polycythemia vera • Alcoholism • Pregnancy • Sickle cell disease • Septic emboli • Fadiation • Idiopathic • Dysbarism (caisson disease): scuba diver surfacing too fast • Thermal trauma (burns, frostbite) • Cushing's disease Frequency – Frequency depends on the site involved. – The most common site is the hip, and other locations include the carpals, talus, and humerus. – US approximately 15,000 new cases are reported each year. – AVN accounts for >10% of total hip replacement surgeries performed in the United States. Patient Profile • Sex: Depends on the underlying cause, the overall male- to-female ratio is 8:1. • Age: Age at onset depends on the underlying cause. Primary AVN most often occurs during the forth or fifth decade, and it is bilateral in 40-80% of cases. On average, women present almost 10 years later than men. • Race: No racial predilection exists except for AVN associated with sickle cell disease and hemoglobin S and SC disease, which predominantly occur in people of African and Mediterranean descent. Methods of Imaging Imaging Findings Time to Comments Method Diagnosis X-Ray Osteopenia Months Sensitivity poor Reactive sclerosis Specificity good Subchondral Collapse (late) CT Reactive sclerosis Weeks to Sensitivity poor Subchondral collapse Months Specificity OK Bone Scan Decreased uptake early Weeks Sensitivity good Increased uptake late Specificity poor MRI Change of signal in Days Sensitivity excellent marrow pattern Specificity good MRI Diagnosis of AVN • MRI is the most sensitive noninvasive method for diagnosis of AVN. • Diagnosis involves detection of marrow foci of decreased signal on T1-weighted images and the characteristic double line sign on T2- weighted images. (only condition that will do the double line) MRI Diagnosis of AVN - T1 • AVN is diagnosed when a peripheral band of low signal intensity is present on all imaging sequences, typically in the superior portion of the femoral head, outlining a central area of marrow. • This peripheral band is most apparent on T1- weighted sequences. MRI Diagnosis of AVN - T2 • On conventional T2 sequences, the inner border of the peripheral band shows high signal in 80% of cases. • This is called the "double - line" sign of avascular necrosis, and is considered to be pathognomonic. MRI Findings T2 with Fat Supression
• Fat suppression is current
state of the art. • Dark, peripheral band of AVN that is not seen in contrast to the inner high signal band of AVN. • Early edema of marrow allowed MR to surpass bone scans in early diagnosis. MRI Findings – Joint Effusions • Increased joint fluid is commonly associated with AVN, and its presence does not indicate a septic joint effusion. • The frequent presence of joint effusions has led to the hypothesis that patients are presenting with pain due to their effusion, rather than the long-standing process of AVN. Staging AVN Ficat and Arlet Staging of AVN: (Radiographic staging)
Stage X-Ray MRI Bone Scan
0 Negative Marrow edema Maybe positive
Accidental finding 1 Osteopenia (hindsight) + bone necrosis Positive Missed here and #2 s picture perfect technique 2 Diffuses osteoporosis and sclerosis + joint edema Positive on plain films. A reactive shell of bone delimits the infarct. Spherical femoral head. 3 Crescent sign (radiolucency) under + articular Positive the subchondral bone representing cartilage a fracture. Joint space preserved involvement 4 Femoral head collapse. Joint space + specificity of Positive narrowing – OA joint NEED SURGERY HERE AND 3 destruction Stage 0 Stage 1 Stage 2 Stage 3 (crescent sign in frogleg) Stage 4 Last Case
• 45 year old male
• Chronic LBP & hip pain • No response to conservative care after two weeks. • MRI recommended patient wanted to wait… The End