Osteonecrosis of Hip

Author: Doug Nowak

Topic updated on 10/15/12 9:56am

Introduction

Also know as Avascular Necrosis
Pathogenesis
- intravascular coagulation is the final common pathway
  1. coagulation of the intraosseous microcirculation →
  2. venous thrombosis →
  3. retrograde arterial occlusion →
  4. intraosseous hypertension →
  5. decreased blood flow to femoral head →
  6. AVN of femoral head →
  7. chondral fracture and collapse
Risk factors
- alcoholism
- dysbaric disorders (decompression sickness, "the bends")
- marrow-replacing diseases (e.g. Gaucher's disease)
- sickle cell disease
- hypercoagulable states
- steroids (either endogenous or exogenous)
- SLE
- Inflammatory Bowel Disease
- transplant patient
- virus (CMV, hepatitis, HIV, rubella, rubeola, varicella)
- protease inhibitors (type of HIV medication)
- trauma
AVN associated with trauma
- due to injury of femoral head blood supply (medial femoral circumflex)
- AVN rates of specific injuries
  - femoral head fracture: 75-100%
  - basicervical fracture: 50%
  - cervicotrochanteric fracture: 25%
  - hip dislocation: 2-40% (2-10% if reduced within 6 hours of injury)
  - intertrochanteric fracture: rare
- higher risk of AVN with greater initial displacement and poor reduction
- decompression of intracapsular hematoma may reduce risk
- quicker time to reduction may reduce risk

Presentation

Symptoms
- insidious onset of pain
Physical exam
- mostly normal initially
- advanced stages similar to hip OA (limited motion, particularly internal rotation)

Imaging

Radiographs
- work-up should include
  - AP pelvis
  - AP hip
  - frog-lateral of the hip
- classification systems based largely on radiographic findings (see below)
MRI
- highest sensitivity and specificity
- T1: dark
- T2: bright (marrow edema)
Bone scan

Classification

Steinberg Classification (modification of Ficat classification)
Stage	Radiographs	MRI	Images
O	Normal Xray	normal MRI and bone scan
I	Normal Xray	abnormal MRI and/or bone scan
II	Xray - cystic or sclerosis changes	abnormal MRI and/or bone scan
III	Xrays - crescent sign (subchondral collapse)	abnormal MRI and/or bone scan
IV	Xray - flattening of femoral head	abnormal MRI and/or bone scan
V	Xray - narrowing of joint	abnormal MRI and/or bone scan
VI	Xray - advanced degenerative changes	abnormal MRI and/or bone scan

Treatment

Nonoperative
- bisphosphonates
  - indicated for precollapse AVN (Ficat stages 0-II)
  - trials have shown that alendronate prevents femoral head collapse in osteonecrosis with subchondral lucency
    - However, other studies have also shown no benefit of preventing collapse with bisphosphonates
Operative
- core decompression
  - indications
    - for early AVN, before subchondral collapse occurs
  - mechanism: relieves intraosseous hypertension
- rotational osteotomy
  - indications
    - only for small lesions (<50%) in which the lesion can be rotated away from a weight bearing surface
  - technique
    - typically performed through intertrochanteric region
- vascularized free-fibula transfer
  - indications
    - for both pre-collapse and collapsed AVN in young patient
  - technique
    - fibular strut is placed under subchondral bone to help prevent collapse or tamp up small areas of collapse
  - complications
    - are related to donor site morbidity
      - sensory deficit
      - motor weakness
      - FHL contracture
      - tibial stress fracture from side graft is taken
- total hip replacement
  - indications
    - in advanced femoral head collapse, acetabular DJD
  - outcomes
    - in young patients with osteonecrosis there is a higher rate of linear wear of the polyethylene liner and a higher rate of osteolysis than when compared to older patients who have THA for osteoarthritis
- total hip resurfacing
  - indications
    - in advanced DJD with small, isolated focus of AVN
    - contraindicated in underlaying disease process or chronic steroid use causing AVN (poor bone quality) and renal disease (metal ions from metal-on-metal implant)
- hip arthrodesis
  - indications
    - only consider in the very young patient in a labor intensive occupation

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Qbank (4 Questions)

TAG

(OBQ11.196) A 47-year-old man presents with 1 week of left leg pain. 6 months prior he underwent a vascularized free-fibula bone graft from his left leg to his right hip for avascular necrosis. The pain is located at the level of his donor site and is worse with weight-bearing and relieved by rest. Physical exam shows focal tenderness over his tibia. A lateral radiograph from the day of presentation is shown in Figure A. WBC, ESR, and CRP are all within normal limits. What is the next best step in management to confirm the diagnosis? Topic

Review Topic

FIGURES: A

1. Compartment pressure measurements
2. CT scan
3. MRI scan
4. Ultrasound to rule out deep abscess
5. Bone biopsy

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is suspicious for a stress fracture of the tibia following free-fibula bone grafting. If plain radiographs are negative, more sensitive imaging such as a MRI or bone scan should be performed.

Tibial stress fractures are a known complication following free-fibula bone grafting. Radiographs may be normal (as is the case in figure A), or might show the "dreaded black line" and/or new periosteal bone formation. If a stress fracture is confirmed with imaging, appropriate management would then consist of protective weight bearing until symptoms subside.

Pacifico et al detail a case report of tibial stress fractures after vascularised free-fibula graft to the mandible. They report non-traumatic stress fracture to the tibia following a vascularised free-fibula graft is an uncommon but important complication.

Ivey et al detail a case report of a tibial stress fracture after vascularised free-fibula graft for repair of non-union of the humerus.

Emery et al report a case-series of 5 patients who sustained tibial stress fractures after a graft had been obtained from the ipsilateral fibula for use in anterior reconstruction of the spine. They theorize that the increased load the tibia bears as a result of the missing fibular graft may result in stress fractures.

Illustration A shows new periosteal bone formation on the lateral cortex of the tibia consistent with a stress fracture.

Incorrect Answer Choices:
1: While compartment syndrome is on the differential diagnosis, his signs and symptoms are not most consistent with that diagnosis.
2: While CT scan may show evidence of a stress fracture, MRI/bone scans have been shown to be superior methods for detection.
4: As infectious laboratories are normal, an ultrasound to rule out a deep abscess would likely be negative.
5: Bone biopsy is not appropriate without evidence of a lesion or concern for osteomyelitis.

Illustrations: A

REFERENCES:

1. Pacifico MD, Floyd D, Wood SH. Tibial stress fracture as a complication of free-fibula vascularized graft for mandibular reconstruction. Br J Plast Surg. 2003 Dec;56(8):832-4. PMID:14615264 (Link to Abstract)

2. Ivey M, Hicks CA, Hook JD. Stress fracture of the tibia after harvest of a vascularized fibular graft for repair of nonunion of the humerus. Orthopedics. 1995 Jan;18(1):57-60. PMID:7899169 (Link to Abstract)

3. Emery SE, Heller JG, Petersilge CA, Bolesta MJ, Whitesides TE Jr. Tibial stress fracture after a graft has been obtained from the fibula. A report of five cases. J Bone Joint Surg Am. 1996 Aug;78(8):1248-51. PMID:8753718 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, Michael Hughes MD, Ben Taylor MD,

Please Rate Educational Value!

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TAG

(OBQ09.8) In patients with sickle cell disease and asymptomatic osteonecrosis of the femoral head identified with magnetic resonance imaging, what percentage will eventually go on to femoral head collapse? Topic

Review Topic

1. < 10%
2. 11% to 25%
3. 26 to 50%
4. 51 to 75%
5. > 75%

PREFERRED RESPONSE ▶

DISCUSSION: Untreated asymptomatic osteonecrosis of the femoral head in patients with sickle cell disease has a > 75% likelihood of progression to pain and collapse.

Hernigou et al studied patients with sickle cell disease who had symptomatic AVN in one hip and asymptomatic AVN in the contralateral hip. Their goal was to understand the natural history of the asymptomatic side. Ninety-one percent eventually developed pain and 77% developed collapse. Collapse was preceded by symptoms of pain in all patients.

Aguilar et al report bone and joint disorders are the most common cause of chronic pain in patients who have sickle cell disease, and the femoral head is the most common area of bone destruction in sickle cell patients.

REFERENCES:

1. Hernigou P, Habibi A, Bachir D, Galacteros F. The natural history of asymptomatic osteonecrosis of the femoral head in adults with sickle cell disease. J Bone Joint Surg Am 2006;88:2565- 2572 PMID:17142405 (Link to Abstract)

2. Aguilar C, Vichinsky E, Neumayr L. Bone and joint disease in sickle cell disease. Hematol Oncol Clin North Am 2005;19:929-941 PMID:16214653 (Link to Abstract)

Question Authors:

Derek Moore, Patrick McCulloch MD, Patrick McCulloch MD,

Please Rate Educational Value!

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TAG

(OBQ08.239) A 40-year-old man complains of increasing groin pain. Radiographs show femoral head avascular necrosis with subchondral lucency but without femoral head collapse. Which of the following medical treatments have been shown to decrease the risk of subsequent femoral head collapse? Topic

Review Topic

1. Cyclic parathyroid hormone therapy
2. Bisphosphonate therapy
3. RANK ligand therapy
4. RANK therapy
5. Selective estrogen receptor modulator therapy

PREFERRED RESPONSE ▶

DISCUSSION: Bisphosphonate therapy is a proven method of preventing femoral head collapse in patients with avascular necrosis and subchondral lucency.

Lai et al evaluated the effect of alendronate on patients with Steinberg stage-II or III osteonecrosis of the femoral head. They found that alendronate prevented early collapse of the femoral head at twenty-four months.

Agarwala et al evaluated the effect of bisphosphonate therapy on patient reported and radiographic outcomes in femoral head avascular necrosis. They found alendronate reduces pain, improves function and may prevent disease progression at 5 year followup.

Nishii et al evaluated the effect of alendronate on 20 hips with osteonecrosis of the femoral head without collapse. They found a lower frequency of collapse and less patient reported pain in patients treated with bisphosphonate therapy compared to controls at 12 month follow up.

Incorrect Answers:
Answer 1: Cyclic parathyroid hormone therapy is used in osteoporosis treatment, and not in the treatment of femoral head avascular necrosis.
Answer 3 & 4: Neither RANK nor RANK ligand are being used in therapeutic forms currently. Denosumab, an anti-RANK ligand antibody, has shown early success in the treatment of bone lysis in oncologic applications.
Answer 5: Selective estrogen receptor modulator therapy is used in osteoporosis, and not in the treatment of femoral head avascular necrosis.

REFERENCES:

1. Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. 2005 Oct;87(10):2155-9. PMID:16203877 (Link to Abstract)

2. Agarwala S, Jain D, Joshi VR, Sule A. Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford). 2005 Mar;44(3):352-9. PMID:15572396 (Link to Abstract)

3. Nishii T, Sugano N, Miki H, Hashimoto J, Yoshikawa H. Does alendronate prevent collapse in osteonecrosis of the femoral head? Clin Orthop Relat Res. 2006 Feb;443:273-9. PMID:16462451 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 11 Ratings

TAG

(OBQ04.220) A 41-year-old male has steroid-induced avascular necrosis of the hip and decides to undergo metal on polyethylene total hip arthroplasty. His 80-year-old, sedentary father had a total hip replacement 5 years ago. With comparison to his father, the patient should be informed of the following risk? Topic

Review Topic

1. Increased risk of sciatic nerve palsy
2. Increased longevity of prothesis
3. Increased risk for polyethylene wear and osteolysis
4. Reduced range of motion
5. Lower likelihood of revision surgery

PREFERRED RESPONSE ▶

DISCUSSION: A younger, active patient will sustain more polyethylene wear and osteolysis due to greater activity levels and more years of use.

Kim et al prospectively studied 98 consecutive patients with osteonecrosis of the femoral head with an average follow-up was 9.3 years. Although there was no aseptic loosening of the components, they reported a high rate of linear wear of the polyethylene liner and a high rate of osteolysis in these high-risk young patients (16% in cemented femoral stems, 24% in uncemented stems).

REFERENCES:

1. Kim YH, Oh SH, Kim JS, Koo KH. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003 Apr;85-A(4):675-81. PMID:12672844 (Link to Abstract)

Question Authors:

John Badylak MD, Derek Moore, Michael Hughes MD,

Please Rate Educational Value!

3.0

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Cases

AVN (C1090)

Recon - - Osteonecrosis of Hip

HPI - 6 month history of left hip pain with evidence of AVN but no collapse

21 y/o female with sickle cell disease and bilateral avn without any eviden...

11/16/2011

33 responses

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Groups

ABOS II: Osteonecrosis

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. 2005 Oct;87(10):2155-9. PMID:16203877 (Link to Abstract)
Agarwala S, Jain D, Joshi VR, Sule A. Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford). 2005 Mar;44(3):352-9. PMID:15572396 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Nishii T, Sugano N, Miki H, Hashimoto J, Yoshikawa H. Does alendronate prevent collapse in osteonecrosis of the femoral head? Clin Orthop Relat Res. 2006 Feb;443:273-9. PMID:16462451 (Link to Abstract)

Level of Evidence 4 (Case Series)

Emery SE, Heller JG, Petersilge CA, Bolesta MJ, Whitesides TE Jr. Tibial stress fracture after a graft has been obtained from the fibula. A report of five cases. J Bone Joint Surg Am. 1996 Aug;78(8):1248-51. PMID:8753718 (Link to Abstract)
Kim YH, Oh SH, Kim JS, Koo KH. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003 Apr;85-A(4):675-81. PMID:12672844 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Pacifico MD, Floyd D, Wood SH. Tibial stress fracture as a complication of free-fibula vascularized graft for mandibular reconstruction. Br J Plast Surg. 2003 Dec;56(8):832-4. PMID:14615264 (Link to Abstract)
Ivey M, Hicks CA, Hook JD. Stress fracture of the tibia after harvest of a vascularized fibular graft for repair of nonunion of the humerus. Orthopedics. 1995 Jan;18(1):57-60. PMID:7899169 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Hernigou P, Habibi A, Bachir D, Galacteros F. The natural history of asymptomatic osteonecrosis of the femoral head in adults with sickle cell disease. J Bone Joint Surg Am 2006;88:2565- 2572 PMID:17142405 (Link to Abstract)
Aguilar C, Vichinsky E, Neumayr L. Bone and joint disease in sickle cell disease. Hematol Oncol Clin North Am 2005;19:929-941 PMID:16214653 (Link to Abstract)

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Osteonecrosis of Hip

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