Avascular Necrosis: Causes and Treatment

Coleman D. Fowble, M.D. Midlands Orthopaedics, P.A. Columbia, SC

Introduction
Definition
Loss of blood flow to the bone leading to death of the cellular components of bone.

Avascular Necrosis
AVN Osteonecrosis Aseptic necrosis Ischemic necrosis Bone infarction

Bones Affected
Femoral head most common by far Shoulder humeral head Odontoid (Neck) Scaphoid (Wrist) Lunate (Wrist) Talus (Ankle)

Examples

Treatment
Frustrating Staging very subjective in lower stages

Etiologies
Trauma Alcohol Steroids Diving (Caissons Disease) Sickle Cell Idiopathic (up to 30% of cases)

Symptoms
Pain Decreased range of motion

Risk Factors
Alcoholism Pancreatitis Diabetes Gout

Staging
Initially radiographic staging Revised with advancement of MRI

Classification
Ficat
Original x-ray classification of hip

Other classifications exist for talus, scaphoid, etc.

Stage 0
No clinical symptoms No radiographic abnormalities Microscopic diagnosis

Stage I
May or may not have symptoms Radiographs and CT are normal MRI is abnormal as is bone scan Microscopic exam confirms diagnosis

Stage II
Patient is symptomatic X-rays show osteopenia, sclerosis, cysts No subchondral lucency or collapse MRI confirms diagnosis

Stage III
X-rays show subchondral lucency and collapse
Crescent sign

Shape of femoral head is preserved Subclassified by extent of crescent

IIIa 15% of head IIIb 15-30% of ahead IIIc greater than 30%

Stage IV
Flattening or collapse of head on x-ray Loss of joint space Subclassified by extent of collapse like Stage III
IVa IVb IVc

MRI Stage IV

Stage V
Arthritic changes evident on x-rays with loss of joint space and spurring May affect acetabular side of the joint

Stage V

Stage VI
Extensive destruction of femoral head and joint May be indistinguishable from osteoarthritis

Treatment Options
Stage dependent Clinical signs and symptoms Physiologic condition Age Medical comorbidities

Observation
Normal x-ray Possible abnormal MRI No clinical signs or symptoms

Core Decompression
Stage I or II With or without hardware Age

Core Decompression
Added fixation

Free Vascularized Fibular Graft

Pioneered in 1979 by Dr. Urbaniak at Duke Over 2500 performed Multidisciplinary approach Only center with real consistent results

Core Decompression
Vascularized fibular graft

Partial Resurfacing
No Longer in favor Disastrous results
Loosening Fracture Migration of implant

Hip Replacement
Too much destruction of head Age

Hip Resurfacing
Age Bone preserving More functional hip replacement

Total Hip Versus Resurfacing

Workman's Compensation
Trauma Secondary injury Difficult
May take several years to show up

Femoral Neck Fracture

Basilar neck Transcervical Subcapital Intertrochanteric

Femoral Neck Fracture

Location of fracture determines risk of AVN

Treatment Examples
Fracture pattern determines treatment Other factors
Age Comorbidities

Transcervical Fracture

Fixation
3 Screws Screw and sideplate Intramedullary device

AVN After Treatment

AVN can occur long after treatment

Replacement
Hemiarthroplasty Total hip

Summary
AVN is the disruption of the blood supply to bone There are multiple causes Diagnosis may be delayed Treatment is dependent on stage and other factors

Sources
Staging of Avascular Necrosis. Orthopaedia Main. In: Orthopaedia-Collaborative Orthopaedic Knowledgebase JBJS Br. Core Decompression of the Distal Femur. Vol. 71-B. August, 1989 JBJS. Treatment of Osteonecrosis with Free Vascularized Fibular Graft. Vol 77. 1995