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Osteonecrosis of
Femoral Head
Scope
Definition
Etiology
Pathogenesis
Diagnosis
Treatment
Definition
Disease of impaired osseous
blood flow in which a
circumscribed area of bone
becomes necrosis
Etiology
Traumatic
Non-traumatic
Etiology (Non-traumatic)
Steroid usage
Alcohol
Blood disease
Sickle cell anemia
Hypofibrinolysis
Caisson disease
Connective tissue disease
Idiopathic 15-20%
Etiology
Steroid usage
SLE incidence 15-44%
Oinuma K.
AP pelvis, frog
leg
Crescent sign
Secondary OA
change
Technetium bone scan (Tc
99)
Preradiographic phase AVN
Decrease uptake
MRI
SPECT
(Single-photon emission
computed tomography)
sensitivity 100% in renal
transplant pt.
BONE SPECT
32 AVN of femoral head
SPECT detect 32/32 -> 100%
sensitivity
MRI detect 21/32 -> 66%
sensitivity
procedure
prosthetic replacement
Treatment
Conservative treatment
stage I-II
NWB with crutches (6 wks)
analgesic+exercise
F/U 2 years 80% poor result
15 AVN / nonoperative Rx
100% collapse, Av. Time 23 months
(Bradway and Morrey. J
Arthroplasty;1993)
Joint preserving procedure
Core decompression
Osteotomy
Free vascularized fibular/ iliac
graft
Arthrodesis
Arthroscopic debridement
(+core)
Treatment
Core Decompression
Decrease BMP (bone marrow
pressure)
Increase venous drainage
Promote vascular ingrowth
Bone graft, autologous bone marrow
Treatment of choice stage I-II
Core Decompression
Result of core
decompression
133 AVN, stage I+II, F/U 9.5 years
90% successful clinical result
79% no radiographic progression
(Ficat. JBJS;67B:3-9:1985)
204 AVN, F/U 3 years
no additional operative Rx was necessary
96% stage I
77% stage II
60% stage III
(Zizic and Hungerford. Textbook of Rheumatology Ed 2,
Vol.2:1689-1710)
Electrical stimulation
Goal: Enhance bone formation and
fracture healing
Alone or as an adjunct to other surgical
procedure
PEMP (pulsing electromagnetic fields)
-more effective than symptomatic Rx in
precollapse and minimally collapse
-as effective as core decompression in
precollapse
-more effective as core decompression in
minimally collapse
Osteotomy
Shift the necrotic segment out of
the region of major weight bearing
and replace it with normal bone
and cartilage
Early to intermediate stage that
acetabular cartilage is unaffected
Femoral Osteotomy
Candidate
< 40 years old
degrees)
Mobile hip
union
Result of Ostetomy
Sugioka Y (CORR.
1984)
1984
158 hip (113 ราย) มี
success rate 86-95
%
(1992 , 295 pts,
79%, ave F/U 11 yrs)
Inao S (CORR. 1999)
14 hips(12 ราย) F/U
10-17 ปี มี3 ราย> THR
ถ้า Collapse < 2 mm
จะได้ผล ดีที่ 15 ปี
Treatment
Vascularized bone graft
- fibular, iliac crest
- revascularized
Vascularized bone graft
Goal:
Decompress the femoral head
Remove necrotic bone
Fill necrotic defect with
osteoinductive cancellous bone graft
Support subchondral bone with strut
graft
Enhance revascularized process
Vascularized bone graft
Disadvantage:
Technical demand
More complication
Vascularized bone graft
Advantage: The result is better than
core
decompression in stage II,
III
(Ficat classification)
Result of Vascularized bone
graft
Urbaniak JR (JBJS. 77-A.1995)
mean survival rate= 88% ในผู้ป่วย
stage I , II
Judet H (CORR.2001) FU 18 ปี
พบว่า 80% ของผู้ป่วย 60 ราย stage I,II
ยังได้ผลดีอยู่
Prosthetic replacement
surgery
Limited resurfacing
arthroplasty
Resurfacing arthroplasty
Hemiarthroplasty
Total hip replacement
Limited Resurfacing
Arthroplasty
Result of Limited Resurfacing
Arthroplasty
Mont MA (CORR.2001, J. Arthroplasty
2001.)
ผู้ป่วย 30 รายใน stage III, IV เปรียบเทียบกับผู้ป่วยอีก
ยังคงใช้ได้ดีอยู่
Siguier T (CORR.2001)
ผู้ป่วยstage III 26 ข้อ และ stage IV 10 ข้อ
Hemisurface arthroplasty
Hemisurface or partial
resurfacing arthroplasty
Time-buying procedure for young
and active patient
Adequated bone quality and relative
normal articular cartilage
Bone stock preservation and intact
intramedllary canal
Survivorship 81% at 5.1 years
Survivorship 61% at 10 years
(Amstutz HC. Semin Arthroplasty ;9:261,1998)
Hemiarthroplas
ty
Chan YS
(CORR.2000)
ได้เปรียบเทียบผลการรักษาโดยใ
Rx. 1. Conservative
2. Core decompression
Rx. 1. Conservative
2. Core decompression
Ficat stage II 3. Others
Ficat stage Rx. 1. Conservative
2. Hemiarthroplasty
III 3. Others
Ficat stage Rx. 1. Conservative
IV 2. THR
3. Arthrodesis
Thank You