Avascular Necrosis Femoral Head: Difference between revisions

No edit summary
No edit summary
 
(37 intermediate revisions by 5 users not shown)
Line 1: Line 1:
<div class="editorbox">
'''Original Editor '''¬ [[User:Username|Name as it will appear on the page]]</div><div class="editorbox">'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>
<div class="noeditbox"> This article is currently under review and may not be up to date. Please come back soon to see the finished work! ({{REVISIONDAY}}/{{REVISIONMONTH}}/{{REVISIONYEAR}}) </div>
= Clinically relevant anatomy  =
<div class="editorbox">
'''Original Editor '''[[User:Anouk Toye|Anouk Toye]]


see: [[Hip Anatomy]]<br>
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>
== Introduction ==
[[File:Hip Avascular Necrosis.jpeg|right|frameless|alt=|500x500px]]
[[Avascular Necrosis|Avascular necrosis]] (AN) of the [[Femur|femoral]] head is a pathologic process that results from interruption of [[Blood Physiology|blood]] supply to the [[bone]]. Femoral head ischaemia causes bone marrow and osteocytic death, leading to collapse of the necrotic segment of the head of femur..


= Mechanism of injury / pathological process =
AN of the femoral head has often been described as a multifactorial disease.  Etiopathogenesis is not well understood Risk Factors include:  


[[Image:Head of femur avascular necrosis.jpg|thumb|right]]
*[[Genetics and Health|Genetic predilection]]<ref>Adesina O, Brunson A, Keegan THM, Wun T. Osteonecrosis of the femoral head in sickle cell disease: prevalence, comorbidities, and surgical outcomes in California. Blood Adv. 2017;1(16):1287-1295.</ref>
*[[Corticosteroid Medication|Corticosteroid]] intake<ref>Xie XH, Wang XL, Yang HL, Zhao DW, Qin L. Steroid-associated osteonecrosis: Epidemiology, pathophysiology, animal model, prevention, and potential treatments (an overview). J Orthop Translat. 2015 Apr;3(2):58-70. </ref>
*[[Alcoholism|Alcohol]]
* Smoking
* Various [[Chronic Disease|chronic diseases]] <ref>Jaffré C, Rochefort GY. Alcohol-induced osteonecrosis--dose and duration effects. Int J Exp Pathol. 2012;93(1):78-9
</ref> eg [[Sickle Cell Anemia|sickle cell disease]], [[Human Immunodeficiency Virus (HIV)|human immunodeficiency virus]] , hypercoagulable states, [[Autoimmune Disorders|autoimmune disorder]]<nowiki/>s<ref name=":0">Orthobullets Hip Osteonecrosis Available: https://www.orthobullets.com/recon/5006/hip-osteonecrosis<nowiki/>(accessed 15.12.2022)</ref><ref name="Mont">Mont MA, Jones LC, Hungerford DS. Non-traumatic avascular necrosis of the femoral head: ten years later. J Bone Joint Surg Am. 2006;88:1117-1132</ref>.


Avascular necrosis of the femoral head, also known as osteonecrosis, although this term isn’t used that much anymore, is characterized by variable areas of dead trabecular bone and bone marrow, extending to and including the subchondral plate. Most of the time it is the anterolateral region of the femoral head that is affected but no area is necessarily spared. This disease is often seen in patients in the third, fourth and fifth decade. The older the patients, the less the chance of revascularization. We can also state that most radiographically evident lesions progress until the femoral head collapses <ref name="MA">MA Mont and DS Hungerford, Non-traumatic avascular necrosis of the femoral head, J Bone Joint Surg Am. 1995; 77:459-474</ref>.<br>The earliest sign of this mechanical failure is the crescent sign, which represents separation of the subchondral plate from the underlying necrotic concellous bone. After the femoral head has collapsed, most patients have clinical progression resulting in the need for a total hip replacement <ref name="MA">MA Mont and DS Hungerford, Non-traumatic avascular necrosis of the femoral head, J Bone Joint Surg Am. 1995; 77:459-474</ref>.<br>The pathophysiology of avascular necrosis of the femoral head has not been completely accounted for. In some patients there has clearly been a direct cause (trauma, radiation,..), while in others the pathophysiology is still uncertain. Avascular necrosis of the femoral head has often been described as a multfactorial disease. It is associated in some cases with a genetic predilection as well as an exposure to certain risk factors. The most common risk factors are: corticosteroid intake, alcohol use, smoking and various chronic diseases <ref name="Mont">MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132</ref>. Patients with human immunodeficiency virus are also at higher risk for the development of avascular necrosis of the femoral head<ref name="Mont">MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132</ref>. It has to be noted too, that osteonecrosis is a (rare) complication of pregnancy<ref name="Mont">MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132</ref>. Many of these cases are initially misdiagnosed as transient osteoporosis of the hip.&nbsp;  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;  


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;
== Stages ==
AN progresses through four stages:


= Diagnostic procedures =
# Initial/necrosis:blood supply gets disrupted, and necrosis begins
# Fragmentation: the body resorbs the necrotic bone and replaces it with woven bone that is weak and vulnerable to breaking and collapse
# Reossification: stronger bone develops
# Healed/Remodeling: bone regrowth is complete, and final shape present (depending on damage may be normal or abnormal).<ref name=":1" />


It is very important that avascular necrosis is diagnosed early in the disease process since the success of the treatment is related to the stage at which the treatment starts.<br>There are several possible diagnostic modalities:
== Diagnostic procedures ==
[[File:Crescent sign avascular necrosis.jpeg|thumb|Crescent sign]]
It is very important that avascular necrosis is diagnosed early in the disease process as the success of the treatment relates to the stage at which the treatment starts.  


== History and Physical Examination  ==
* Diagnosis be made with [[X-Rays|plain radiographs]] in moderate/late disease but [[MRI Scans|MRI]] may be required to detect early or subclinical osteonecrosis.<ref name=":0" /><ref name="Mont" />
* Crescent Sign: On Xray, a thin, curvilinear lucent line parallel to the [[Bone Cortical And Cancellous|cortical]] margin of the femoral head, in a patient with AN.


Patients are often seen because of pain in the groin, but symptoms can also radiate to the knee or buttocks. On examination, there is usually a painful range on motion, especially on forced internal rotation<ref name="MA">MA Mont and DS Hungerford, Non-traumatic avascular necrosis of the femoral head, J Bone Joint Surg Am. 1995; 77:459-474</ref>. It is also important to track any risk factors before the start of the examination. Investigators need to be wary of avascular necrosis in any patient who has pain in the hip, negative radiographic findings and any of the risk factors, described above. The other hip must also be evaluated.
== History and Physical Examination ==


== Radiographic Evaluation  ==
Patients are often seen because of pain in the groin, but symptoms can also radiate to the [[knee]] or buttocks. On examination, there is usually a painful [[Range of Motion|range of motion]], especially on forced internal rotation<ref name="MA">Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995; 77:459-474</ref>. It is also important to track any risk factors before the start of the examination. Investigators need to be wary of avascular necrosis in any patient who has pain in the [[Hip Anatomy|hip]], negative radiographic findings, and any of the risk factors, described above. The other hip must also be evaluated.


When standard anteroposterior and frog-leg lateral radiographs show obvious avascular necrosis of the femoral head, it is not necessary to perform an MRI.  
== Management ==
[[Image:Head of femur avascular necrosis.jpg|thumb|alt=|Head of femur avascular necrosis]]The precise therapy used depends on many factors, with each patient being evaluated individually for best outcomes. Such factors include the age of the patient, level of pain/discomfort, location and extent of necrosis and comorbidities. Treatments are best implemented at the pre-collapse stage and include both operatives as well as non-operatives options. If left untreated, femoral head AN may lead to subchondral fractures within only 2 to 3 years. The management ranges from conservative to invasive. Conservative management includes physical therapy, restricted weight-bearing, alcohol cessation, discontinuation of steroid therapy, pain control medication, and targeted pharmacologic therapy, among others.


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; [[Image:Hip_X_ray_avascular_necrosis.jpg]]
Generally,


== Magnetic Resonance Imaging  ==
* Non-operative treatments or core decompression are best for asymptomatic and symptomatic small to medium-sized pre-collapse lesions. Conservative managements are physical therapy, restricted weight-bearing, alcohol cessation, discontinuation of steroid therapy, pain control medication, and targeted pharmacologic therapy, among others.
* Medium to larger-sized lesions can have treatment with bone grafting (vascularized or non-vascularized), or osteotomies.
* If femoral collapse has occurred or acetabular involvement is present, arthroplasty is indicated.<ref name=":1">Hsu H, Nallamothu SV. StatPearls. StatPearls Publishing; Treasure Island (FL), 2020. Hip Osteonecrosis. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499954/ (Accessed 25 July 2020)</ref><ref>Barney J, Piuzzi NS, Akhondi H. Femoral head avascular necrosis.Available:https://www.ncbi.nlm.nih.gov/books/NBK546658/ (accessed 15.12.2022) </ref>
Core decompression is a surgical procedure that requires surgical drilling into the area of dead bone near the joint, reducing pressure, allows for increased blood flow. This aims to slows or stops bone and/or joint destruction.<ref>Standford medicine Core decompression Available: https://stanfordhealthcare.org/medical-conditions/bones-joints-and-muscles/avascular-necrosis/treatments/core-decompression.html (accessed 15.12.2022)</ref>


This is the best method for cases that are radiographically occult or not obvious on radiographs. It has been found to be 99%sensitive and 98% specific for this disease<ref name="Mont">MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132</ref>.  
=== Physical therapy ===
Conservative management such as physiotherapy is needed to avoid further deterioration of the affected hip. However, while it has been shown to delay the disease progressing, physiotherapy alone cannot cure the process with most clients requiring surgical treatment.  


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; [[Image:Avacular_necrosis_MRI.jpg]]
Physiotherapy treatment aims include:


= Management / interventions =
# Decreasing weight bearing: usually achieved with use of crutches or a walking aid. By using crutches, the load that the hip joint bears, will be decreased. This weight-bearing restriction is an important conservative treatment.
# Education: On prevention, removal or reduction of risk factors such as smoking, alcohol abuse, obesity and corticosteroids
# Range Of Motion: Both passive and active exercises should be initiated. Passive exercises contain passive movements of the hip and stretching exercises. Active exercises consist of 3 dimensional motions of the hip joint and can be applied during standing, sitting on a chair or while lying down. 
# Strengthening exercises: In the next stage, strengthening exercises are added, focusing on the muscles of the hip and thigh. Also include exercises for the core area as they play a large supporting role. To improve functionality it is important to implement endurance training and coordination training in a more advanced stage of the therapy. Endurance can be trained by walking on a treadmill or cycling on a home trainer. To improve coordination, walking exercises with increased complexity and balancing exercises can be adopted in physical therapy sessions.


== 1. Non-operative Treatment  ==
Physical therapy after surgery is also a key component for recovery. It starts immediately the day after surgery. Prepare the patients for discharge by showing them how to do their everyday activities like getting in and out of bed and walking with a walker or crutches.  


=== a. Observation or Protected Weight-Bearing ===
In a more advanced stage of the therapy, the therapist instructs the patient on exercises to strengthen their muscles, improve range of motion, work on balance and gait speed. The patient specifically learns how to move, while maintaining hip precautions. The rehabilitation protocol is combined with a home exercise program.<ref>Paula Miller, Treating Avascular Necrosis, 21(17):23</ref>  


This method is believed to slow the progression of avascular necrosis so that the femoral head wouldn’t collapse. However more than 80% of affected hips do progress to femoral head collapse and arthritis by four years after the diagnosis<ref name="Mont">MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132</ref>. There are various methods to reduce weight-bearing. The concept of this method is to reduce the forces on the hip joint. This (interventional) treatment has various modalities, such as a cane, crutch, walker or two crutches.<br>Most studies have shown though that non-operative treatment yields poor results. The only condition for which protected weight-bearing might be effective is a type-A lesion<ref name="MA">MA Mont and DS Hungerford, Non-traumatic avascular necrosis of the femoral head, J Bone Joint Surg Am. 1995; 77:459-474</ref>.
[[Avascular Necrosis|See avascular necrosis page]]<br>  
 
== References  ==
=== b. Pharmacological Treatment  ===
 
=== c. Electrical stimulation  ===
 
Electrical stimulation has been shown experimentally to enhance osteogenesis and neovascularization as well as to alter osseus turnover.<ref name="MA">MA Mont and DS Hungerford, Non-traumatic avascular necrosis of the femoral head, J Bone Joint Surg Am. 1995; 77:459-474</ref><br>Three different methods can be described:
 
*Non-invasive pulsed electromagnetic-field stimulation
*Direct-current stimulation of the necrotic area through insertion of an electrode at the time of a core decompression
*Non-invasive direct-current stimulation by capacitive coupling after a core decompression
 
Electrical stimulation remains experimental for the treatment of avascular necrosis of the femoral head. Additional study is needed to define the optimum dosage, application, and timing of treatment.&nbsp;<ref name="MA">MA Mont and DS Hungerford, Non-traumatic avascular necrosis of the femoral head, J Bone Joint Surg Am. 1995; 77:459-474</ref>
 
== 2. Operative Treatment  ==
 
There are several possible ways to treat avascular necrosis of the hip: core decompression, Core decompression with electrical stimulation, Osteotomy, Non-vascularized bone-grafting and Vascularized grafts.<br>
 
=== Recommendations for treatment<br><br>  ===
 
[[Image:Table 1.jpg]]<br>  
 
[[Image:Table 2.jpg]]<br>
 
[[Image:Table 3.jpg]]<br>
 
All tables come from: MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132 <ref name="Mont">MA Mont, LC Jones and DS Hungerford, Non-traumatic avascular necrosis of the femoral head: ten years later, J Bone Joint Surg Am. 2006;88:1117-1132</ref><br>
 
<br>
 
= References  =


<references />
<references />
[[Category:Hip]] 
[[Category:Conditions]]
[[Category:Hip - Conditions]]

Latest revision as of 15:42, 15 December 2022

This article is currently under review and may not be up to date. Please come back soon to see the finished work! (15/12/2022)

Original Editor Anouk Toye

Top Contributors - Lucinda hampton, Anouk Toye, Kim Jackson, Uchechukwu Chukwuemeka, Aarti Sareen, Admin and 127.0.0.1

Introduction[edit | edit source]

Avascular necrosis (AN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. Femoral head ischaemia causes bone marrow and osteocytic death, leading to collapse of the necrotic segment of the head of femur..

AN of the femoral head has often been described as a multifactorial disease. Etiopathogenesis is not well understood Risk Factors include:

                                    

Stages[edit | edit source]

AN progresses through four stages:

  1. Initial/necrosis:blood supply gets disrupted, and necrosis begins
  2. Fragmentation: the body resorbs the necrotic bone and replaces it with woven bone that is weak and vulnerable to breaking and collapse
  3. Reossification: stronger bone develops
  4. Healed/Remodeling: bone regrowth is complete, and final shape present (depending on damage may be normal or abnormal).[6]

Diagnostic procedures[edit | edit source]

Crescent sign

It is very important that avascular necrosis is diagnosed early in the disease process as the success of the treatment relates to the stage at which the treatment starts.

  • Diagnosis be made with plain radiographs in moderate/late disease but MRI may be required to detect early or subclinical osteonecrosis.[4][5]
  • Crescent Sign: On Xray, a thin, curvilinear lucent line parallel to the cortical margin of the femoral head, in a patient with AN.

History and Physical Examination[edit | edit source]

Patients are often seen because of pain in the groin, but symptoms can also radiate to the knee or buttocks. On examination, there is usually a painful range of motion, especially on forced internal rotation[7]. It is also important to track any risk factors before the start of the examination. Investigators need to be wary of avascular necrosis in any patient who has pain in the hip, negative radiographic findings, and any of the risk factors, described above. The other hip must also be evaluated.

Management[edit | edit source]

Head of femur avascular necrosis

The precise therapy used depends on many factors, with each patient being evaluated individually for best outcomes. Such factors include the age of the patient, level of pain/discomfort, location and extent of necrosis and comorbidities. Treatments are best implemented at the pre-collapse stage and include both operatives as well as non-operatives options. If left untreated, femoral head AN may lead to subchondral fractures within only 2 to 3 years. The management ranges from conservative to invasive. Conservative management includes physical therapy, restricted weight-bearing, alcohol cessation, discontinuation of steroid therapy, pain control medication, and targeted pharmacologic therapy, among others.

Generally,

  • Non-operative treatments or core decompression are best for asymptomatic and symptomatic small to medium-sized pre-collapse lesions. Conservative managements are physical therapy, restricted weight-bearing, alcohol cessation, discontinuation of steroid therapy, pain control medication, and targeted pharmacologic therapy, among others.
  • Medium to larger-sized lesions can have treatment with bone grafting (vascularized or non-vascularized), or osteotomies.
  • If femoral collapse has occurred or acetabular involvement is present, arthroplasty is indicated.[6][8]

Core decompression is a surgical procedure that requires surgical drilling into the area of dead bone near the joint, reducing pressure, allows for increased blood flow. This aims to slows or stops bone and/or joint destruction.[9]

Physical therapy[edit | edit source]

Conservative management such as physiotherapy is needed to avoid further deterioration of the affected hip. However, while it has been shown to delay the disease progressing, physiotherapy alone cannot cure the process with most clients requiring surgical treatment.

Physiotherapy treatment aims include:

  1. Decreasing weight bearing: usually achieved with use of crutches or a walking aid. By using crutches, the load that the hip joint bears, will be decreased. This weight-bearing restriction is an important conservative treatment.
  2. Education: On prevention, removal or reduction of risk factors such as smoking, alcohol abuse, obesity and corticosteroids
  3. Range Of Motion: Both passive and active exercises should be initiated. Passive exercises contain passive movements of the hip and stretching exercises. Active exercises consist of 3 dimensional motions of the hip joint and can be applied during standing, sitting on a chair or while lying down.
  4. Strengthening exercises: In the next stage, strengthening exercises are added, focusing on the muscles of the hip and thigh. Also include exercises for the core area as they play a large supporting role. To improve functionality it is important to implement endurance training and coordination training in a more advanced stage of the therapy. Endurance can be trained by walking on a treadmill or cycling on a home trainer. To improve coordination, walking exercises with increased complexity and balancing exercises can be adopted in physical therapy sessions.

Physical therapy after surgery is also a key component for recovery. It starts immediately the day after surgery. Prepare the patients for discharge by showing them how to do their everyday activities like getting in and out of bed and walking with a walker or crutches.

In a more advanced stage of the therapy, the therapist instructs the patient on exercises to strengthen their muscles, improve range of motion, work on balance and gait speed. The patient specifically learns how to move, while maintaining hip precautions. The rehabilitation protocol is combined with a home exercise program.[10]

See avascular necrosis page

References[edit | edit source]

  1. ↑ Adesina O, Brunson A, Keegan THM, Wun T. Osteonecrosis of the femoral head in sickle cell disease: prevalence, comorbidities, and surgical outcomes in California. Blood Adv. 2017;1(16):1287-1295.
  2. ↑ Xie XH, Wang XL, Yang HL, Zhao DW, Qin L. Steroid-associated osteonecrosis: Epidemiology, pathophysiology, animal model, prevention, and potential treatments (an overview). J Orthop Translat. 2015 Apr;3(2):58-70. 
  3. ↑ Jaffré C, Rochefort GY. Alcohol-induced osteonecrosis--dose and duration effects. Int J Exp Pathol. 2012;93(1):78-9
  4. ↑ 4.0 4.1 Orthobullets Hip Osteonecrosis Available: https://www.orthobullets.com/recon/5006/hip-osteonecrosis(accessed 15.12.2022)
  5. ↑ 5.0 5.1 Mont MA, Jones LC, Hungerford DS. Non-traumatic avascular necrosis of the femoral head: ten years later. J Bone Joint Surg Am. 2006;88:1117-1132
  6. ↑ 6.0 6.1 Hsu H, Nallamothu SV. StatPearls. StatPearls Publishing; Treasure Island (FL), 2020. Hip Osteonecrosis. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499954/ (Accessed 25 July 2020)
  7. ↑ Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995; 77:459-474
  8. ↑ Barney J, Piuzzi NS, Akhondi H. Femoral head avascular necrosis.Available:https://www.ncbi.nlm.nih.gov/books/NBK546658/ (accessed 15.12.2022)
  9. ↑ Standford medicine Core decompression Available: https://stanfordhealthcare.org/medical-conditions/bones-joints-and-muscles/avascular-necrosis/treatments/core-decompression.html (accessed 15.12.2022)
  10. ↑ Paula Miller, Treating Avascular Necrosis, 21(17):23
Retrieved from "https://www.physio-pedia.com/index.php?title=Avascular_Necrosis_Femoral_Head&oldid=323290"