AVASCULAR NECROSIS OF BONE

Dr Shoaib Shaikh
Orthopaedic surgeon
FICAT AND ARLET CLASSIFICATION - OSTEONECROSIS OF FEMORAL HEAD
STERNBERG’S STAGING OF AVN HIP / UNIVERSITY
OF PENNSYLVANIA SYSTEM
The crescent sign of avascular necrosis is seen
on conventional radiographs and refers to a
linear area of subchondral lucency seen most
frequently in the anterolateral aspect of the
proximal femoral head (which is optimally
depicted on the frog-leg radiographic view).

The crescent sign is caused by the necrotic

and repair processes that occur during
avascular necrosis.
It indicates imminent articular collapse.
 Management
• Clinical suspicion – Early Diagnosis –
Examination and history – Previous trauma ,
Steroid intake for prolonged period , alchohol
intake , smoking , coagulation
disorders ,metbolic disorders
• Investigation – X ray and MRI scan
• Staging
• Treatment according to stage of disease
STERNBERG’S STAGING OF AVN HIP / UNIVERSITY
OF PENNSYLVANIA SYSTEM
 Stage 0-II - Sternberg
• Core decompression and BG +/- Electric
stimulation
• Free vascularised bone grafting ( If appropriate
facilities for microsurgical repair present )
• Osteotomies in very late stages
 Stage III-IV A
• Osteotomy when there is minimal flattening of
femur head
• Valgus – Flexion osteotomy if anterolateral
lesion
• Varus extension osteotomy when lesion is more
central
• Mc Murray Osteotomy
• Sugioka – Rotational Osteotomy
 Stage IVB-IVC
• Only non reconstructive therapy is Sugioka’s
Osteotomy
• Total Hip replacement is the best treatment .
• Bipolar Hemiarthroplasty is used when disease
has not involved the acetabulum cartilage
( although rarely done these days for AVN)
 Stage V-VI
• TOTAL HIP ARTHROPLASTY
 Non – Operative methods
• Abductor muscle , Hip rotators strengthening and
stretches
• Local anti inflammatory drugs for pain
• Bisphosphonates may have a role
• Protected weight bearing – Using canes
• Pulse electromagnetic stimulation ?
 Core decompression
• Principle – Removing necrotic bone
decompresses the rigid osseous chamber ,
thus improving blood flow and preventing
additional ischemic episodes
• Core decompression +/- adjuvants like BMP
( bone morphogenic protein ) DMB
(Demineralised bone matrix) or PEMF
 Bone grafting
• Core decompression with bone grafting –
Cancellous , Cortical strut , Osteochondral
• Local muscle pedicle graft – Meyer’s
procedure ( Quadratus Femoris )
• Free vascularised bone graft
 Phemister
• Phemister was the first to introduce the
technique of using cortical strut graft in the
core decompression channel .
 Meyer’s Procedure
• Muscle pedicle graft based on quadratus
femoris muscle with cancellous bone chips
and resurfaced it with cadaveric fresh
osteochondral grafts
 Baksi et al
• Multiple drilling and using muscle pedicle graft
based on tensor fasia lata muscle anateriorly
Free Vasuclarised fibula grafting
 Osteotomy
• Valgus / Flexion Osteotomy described by
Wagner when lesion is anterolateral and the
total angle of necrosis is less than 200 degrees
, a young and active patient
• Varus / Extension Osteotomies when lesion is
more central
• Sugioka Rotational Osteotomy
 Reconstruction
• Total Hip replacement
• Bipolar ( Hemi arthroplasty )
 ABANDONED
THR > HEMIARTHROPLASTY (BIPOLAR)
 AVN in Children
• Two types of AVN occur in childhood. The first
is the idiopathic type best characterized by
Legg-Calvé-Perthes' disease associated with
repeated infarctions that slow the healing
process. The second is the traumatic type
caused by a direct insult to the blood supply of
the developing femoral head. Both can result in
profound growth disturbances of the proximal
femur and early degenerative changes.
Osteochondrosis of femoral head

LEGG – CALVE – PERTHES DISEASE

MRI SCAN
The Gage sign is a V-shaped lucent defect at
the lateral portion of the epiphysis and/or
adjacent metaphysis. It is pathognomonic for
Legg-Calve-Perthes disease.
Waldenström sign is the increased distance
between the pelvic teardrop and the femoral
head. It is a highly specific sign of a hip
joint effusion.
 Management
• Self healing disorder
• Prevention of femoral head deformity and
secondary degenerative OA is the only
justification of treatment
• Goal – Containment of femur head – If this is
done then the femur head can reform in a
concentric manner by what Salter has called
as biological plasticity
 1.Observation
• Children less than 6 with Catterall groups 1 &
2 / Salter group A , good ROM
• No evidence of radiological extrusion of femur
head or collapse
• NWB / Protected weight bearing , activity
restriction , exercises .
• Regular 3 month follow up
2. Intermittent symptomatic treatment
• Temporary / periodic treatment with bed rest
and abduction ( skin traction )
• Stretching exercises
• Follow up 2 months interval
• May need prolonged rest and abduction
3.Definitive Non Operative early treatment

• Non surgical methods – More than 6 years ,

Catterall group 3 or 4 / loss of containment
manisfested on AP view .
• Abduction bracing + Exercises .
• Bracing is generally stopped by about 20
months or when radiographic evidence of
subchondral layer of new bone seen
 4.Early surgical methods
• MRI before surgery is a must
• Ability to obtain containment of head which
enhances remodelling
• Innominate osteotomy – Salter , VDRO , Lateral
opening wegde osteotomy
• Combined innominate and femoral osteotomy
• Lateral shelf procedure
• Valgus extension osteotomy
• Chiari osteotomy
TRIPLE INNOMINATE OSTEOTOMY
VARUS DEROTATION OSTEOTOMY