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Osteonecrosis of the Hip: Diagnosis and Management of Ficat I and II

Osteonecrosis of the Hip: Diagnosis and Management of Ficat I and II. Natasha Holder, MD, MSc . PGY-1. Overview. Osteonecrosis of the femoral head Etiology, Pathogenesis Clinical Presentation Diagnosis Classification of AVN Management of Stage I and Stage II Non-Operative

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Osteonecrosis of the Hip: Diagnosis and Management of Ficat I and II

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  1. Osteonecrosis of the Hip: Diagnosis and Management ofFicat I and II Natasha Holder, MD, MSc. PGY-1

  2. Overview • Osteonecrosis of the femoral head • Etiology, Pathogenesis • Clinical Presentation • Diagnosis • Classification of AVN • Management of Stage I and Stage II • Non-Operative • Core Decompression • Bone Grafting • Osteotomy

  3. Osteonecrosis of the Femoral Head • AKA avascular necrosis or aseptic necrosis • Disruption of the blood flow to the femoral head (traumatic or nontraumatic) • Commonly affects patients between 20 and 50 years of age • Ultimate goal of treatment of ON of the hip is preservation of the femoral head

  4. Risk Factors for Osteonecrosis • Trauma • Corticosteroid use • Alcohol abuse • Smoking • Sickle cell anemia • Coagulopathies • Systemic lupus erythematosus • Hypercholesterolemia • Organ Transplantation JAAOS, 1999:250-261

  5. Risk Factors for Osteonecrosis • Gaucher Disease • Caisson Disease • Radiation Therapy • Arterial disorders • Intramedullary hemorrhages • Chronic Pancreatitis • Hypertriglyceridemia • HIV JAAOS, 1999:250-261

  6. Clinical Presentation • Early in the disease process, the condition is painless • Chief complaint is pain • Localized to the groin area, but it may also manifest in the ipsilateral buttock, knee, or greater trochanteric region. • Painful symptoms are usually exacerbated with weight bearing but are relieved by rest

  7. Diagnosis • History • High index of suspicion • Risk factors • Groin pain, night pain • Physical Exam • Pain on internal rotation • Pain with active and passive ROM • Decreased ROM • Antalgic gait • Examine the contralateral hip

  8. Diagnosis • Laboratory tests • R/O systemic disease, coagulopathies • Radiological Tests • Plain film - AP and Frog leg lateral • Cysts, sclerosis or a crescent sign • Crescent sign results from subchondral collapse of the necrotic segment • MRI – Diagnostic Standard • Bone Scan • Special Tests • Bone marrow pressure, venography, biopsy

  9. Ficat and Arlet Classification

  10. Treatment of Osteonecrosis • Non-operative Treatment • Operative Treatment • Core decompression • Non-vascularized bone-grafting • Vascularized bone-grafting • Osteotomy • Non-operative Treatment • Operative Treatment • Core decompression • Non-vascularized bone-grafting • Vascularized bone-grafting • Osteotomy • Limited Femoral Resurfacing Arthroplasty • Total Hip Arthroplasty

  11. Non-Operative Treatment • Restricted weight bearing is NOT an treatment option except in small, asymptomatic lesions outside the weight bearing area • Meta analysis of outcomes of protected weight bearing in 819 patients demonstrated a failure rate >80 % at a mean of 34 months (Mont et al. ClinOrthRelat Res, 1996:169-78)

  12. Non-Operative Treatment • Pharmacological agents: lipid-lowering drugs, anticoagulants, vasodilators and bisphoshonates • Prichett et al. report at a mean of 7.5 years, ON of the femoral head has developed in only 1% of 284 patients who were taking high dose steroids and a statin. (ClinOrthop 2001; 386:173-8)

  13. Non-Operative Treatment • Glueck et al. used enoxaparin (60mg/day for 12 weeks) to treat patients with thrombophillic or hypofribinolytic disorders in early stages of ON • At 2 years, 89% (31/35 hips) had not required surgery and remained at the Ficat I or II stage (ClinOrthRelat Res, 2005:164-70)

  14. Non-Operative Treatment • Bisphosonates inhibit osteoclast activity and thus curtail bone reabsorption • Agarwala et al. first reported the efficacy of bisphosphonates. Showed an improvement in Harris hip scores, retarded progression of of the disease and reduced rate of collapse (Rhemat. 2005:353-59)

  15. Non-Operative Treatment • Agarwala et al. • prospective study • 395 hips treated with 10 mg alendronate/day • F/U 1-8 years • 92% had a satisfactory result (no surgical intervention) • Patients had improvement in clinical function, a reduction in rate of collapse and a decreased requirement for THA • Improvement is marked if treatment is begun in the pre-collapse stages

  16. Core Decompression • Goal: to decompress the femoral head and reduce the intraosseous pressure • No general agreement on indications or technique • Substantial differences in success rates reported • poor staging of patient pathology • recurrent insults depending on pathology • variations in techniques

  17. Core Decompression • Originally employed by Ficat and Arlet to obtain histological specimens • Decompression reduced bone marrow pressure allowing restoration of blood flow • Stulberg et al. (ClinOrthop 1991, 268:140-51) • Prospective, randomised study, 55 hips • 70% success by Harris Hip score with Ficat I, II, or III stage • Koo et al. (JBJS 1995, 77:870-74) • Randomised control trial, 37 hips • Operative Group: 72% progression and 72% of those that progressed required THA • Non-Operative group: 79% progression and 68% required THA

  18. Core Decompression • Retrospective studies have shown that results of core decompression were substantially worse when there had been collapse of the femoral head preoperatively • Smith et al. (JBJS 1995, 77:674-80) • Retrospective review of 114 hips • Decrease in success rate if the crescent sign had been present • 80% success rate for Ficat I, 20% If crescent sign was present, 0% femoral head collapse

  19. Vascularized Bone Grafting • Rationale: • Decompress the femoral head • Removal necrotic bone • Replacement with autogenouscancellous bone • Support the subchondral bone with a strong and viable bone strut • Revascularization the femoral head

  20. Vascularized Bone Grafting

  21. Vascularized Bone Grafting Urbaniak et al. (JBJS 1995; 77:681-94) • 103 hips, Mean F/U 7 years • Best results were seen in those with small or medium precollapse lesions. • 11% (2/19) of pre-collapse group were converted to THA • 23% (5/22) of post-collapse group were converted to THA • 39% (24/62) of advanced lesion group were converted to THA Berend et al. (JBJS 2003; 85:987-93) • 224 collapsed hips • 64.5% survival rate at a mean 4.3 years (range 2-12) • Relative risk of conversion to THA was associated with an increased lesion size and the amount of collapse

  22. Nonvacularized Bone Grafting • Provides decompression of the femoral head, removal of necrotic bone and structural support and scaffolding to allow repair and remodeling of subchondral bone • 3 distinct approaches • Core tract grafting • Femoral Neck Window - Light bulb procedure. • Trapdoor through articular cartilage of head

  23. Nonvacularized Bone Grafting Lieberman et al. 2002; 84:834-853

  24. Nonvacularized Bone Grafting Meyers et al; JBJS 1973:55A,pg 257

  25. Nonvacularized Bone Grafting • Rosenwasser et al. (ClinOrthop. 1994:306:17-27) • Described the “light bulb” approach • 87% success rate in a study of 15 hips with a mean F/U of 12 years • Mont et al. (ClinOrthop. 2003: 417:84-92) • 86% success rate in a study of 21 hips, light bulb approach • Harris score >80 and no additional procedures

  26. Nonvacularized Bone Grafting • Lieberman et al. (ClinOrthop 2004: 429:139-45) • Retrospective study, 17 hips, Core track method • Used bone morphogenic protein • 14/17 successful result • Harris score >80 and no conversion to THA

  27. Osteotomy • To remove necrotic or collapsing segment from the principle weight-bearing region • Replace this area with a segment of articular cartilage of the femoral head that is supported by healthy, viable bone • 2 Types: • Transtrochanteric Rotational Osteotomies • Intertrochantericvarus/valgusOsteotomies

  28. Rotational Osteotomy • Sugioka et al. • 78% of the 295 hips studied had a successful outcome at a mean of 11 year F/U • Masuda et al. • 69% of 52 hips studied had a successful outcome at a mean of 5 year F/U

  29. Rotational Osteotomy • Best results in young active patients who were not taking corticosteroids, had unilateral involvement with a good preoperative range of hip motion, and had a small lesion without femoral head collapse

  30. IntertrochantericOsteotomy • Less technically demanding • Commonly used in Europe with varying success

  31. IntertrochantericOsteotomy • Merle d’Aubigne et al. ((JBJS(br), 1965; 47:612-33) • Good to excellent pain reduction in 79% of the 75 hips with Ficat II or III. F/U 1 to 6 years. • Mont et al. (JBJS, 1996; 78:1032-38) • Good to excellent Harris hip scores in 76% of the 37 hips studied after treatment with varusosteotomy. F/U mean 11.5 years

  32. IntertochantericOsteotomy • Drescher et al. (JBJS (Br) 2003;85-B:969-74) • 70 intertrochanteric flexion osteotomies. • The mean follow-up was 10.4 years (3.0 to 20.3). • The overall mean Harris hip score increased from 51 points preoperatively to 71 points postoperatively. • A total of 19 hips (27%) underwent total hip arthroplasty at a mean of 8.7 years after osteotomy. • The five-year survival rate was 90%. • Flexion osteotomy is a safe and effective procedure in Ficat stage 2 and 3, preferably with a necrotic angle of <200°

  33. IntertochantericOsteotomy • The size of the osteonecrotic lesion was determined to be a critical factor in the rate of success of the osteotomy

  34. Management of Ficat I and II

  35. Summary • The etiology of ON of the hip may have a genetic basis • The interaction between certain risk factors and a genetic predisposition may determine the course of ON in a particular individual • The role of biological agents in altering the natural history of ON remains to be elucidated • Early diagnosis and intervention prior to collapse is key to successful outcomes of joint preserving procedures

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