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Physiotherapy Guidelines on the Management of Osteonecrosis in Post-SARS Patients

Physiotherapy Guidelines on the Management of Osteonecrosis in Post-SARS Patients

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Published by: 健康生活園Healthy Life Garden on Oct 23, 2009
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Physiotherapy Guidelineson the Management of Osteonecrosisin Post-SARS Patients
Physiotherapy Working Group on SARSCoordinating Committee in PhysiotehrapyHospital AuthorityDecember 2003
Some patients who have been recovering from the Severe Acute Respiratory Syndrome(SARS) have developed osteonecrosis. In a recent press release (Hospital Authority, 2003),it was reported that among the 418 patients being screened with MRI, 49 showedosteonecrosis. The incidence is about 11.7%. Among those with osteonecrosis, 29 (59.2%)had involvement of the hip joint.Currently, there is a paucity of information about the causes of osteonecrosis in post-SARSpatients, although steroid treatment may be considered as one of the risk factors in this groupof patients (HKCOS & HKOA, 2003). However, the prevalence and the natural history of steroid-induced osteonecrosis are still not certain (Assouline-Dayan et al, 2002). Thepresence or absence of pain symptoms in post-SARS patients is not a reliable indicator fordetecting osteonecrosis, especially in the early stages. At present, the MRI is considered asthe first choice of diagnostic method to detect early osteonecrosis (Pavelka, 2000). Thesuccessful management of osteonecrosis would depend on the early detection with treatmentin influencing the natural history of the disease (Lavernia et al, 1999). The orthopaedicsurgeons of the Hospital Authority have come to a consensus of management protocols onosteonecrosis of knee and hip based on the staging systems (HKCOS & HKOA, 2003).
Table 1: Classification and Staging of Osteonecrosis of Knee based on Mont et al (1997)
Stage Criteria Recommended Treatment byHKCOS & HKOA (2003)
I Normal x-ray but abnormal MRI ObservationII Sclerotic or cystic changes, or both, on plainx-ray; normal contour of articular surface andno subchondral fractureObservation or coredecompression or osteotomyIII Subchondral collapse or crescent sign Observation or osteotomyIV Narrowing of joint space with secondarychanges of articular surfaceObservation or knee jointreplacement
Table 2: Classification and Staging of Osteonecrosis of Hip based on the University of Pennsylvania System
Stage Criteria Recommended Treatment byHKCOS & HKOA (2003)
Stage 0 Normal MRI ObservationStage I Normal radiograph; abnormal MRI
 A Mild (<15% of head affected)
Observation if asymptomatic
 B Moderate (15% to 30% of head affected)
Observation or core
C Severe (>30% head affected)
decompression if asymptomaticStage II Lucent and sclerotic changes in femoral head
 A Mild (<15% of head affected)
Observation or core
 B Moderate (15% to 30% of head affected)
decompression or vascularized
C Severe (>30% head affected)
bone graftStage III Subchondral collapse
 A Mild (<15% of head affected)
Observation or vascularized
 B Moderate (15% to 30% of head affected)
bone graft
C Severe (>30% head affected)
Stage IV Flattening of femoral Head
 A Mild (<15% of head affected & <2mmdepression)
Observation or vascularizedbone graft or
 B Moderate (15% to 30% of head affected or 2to 4-mm depression)
hip joint replacement
C Severe (>30% head affected or > 4mmdepression)
Stage V Joint narrowing and/or acetabular change
 A Mild  B ModerateC Severe
Stage VI Advanced degenerative changesThis document is developed by the Physiotherapy Working Group on SARS of theCoordinating Committee in Physiotherapy, Hospital Authority for the management of osteonecrosis in post-SARS patients. It serves as the guidelines for physiotherapistsworking in the Hospital Authority to offer appropriate advice and interventions forpost-SARS patients with suspected or confirmed diagnosis of osteonecrosis.

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