Hip Avascular Necrosis (AVN) |1

Hip Avascular Necrosis (AVN)

Hip osteonecrosis is also known as avascular necrosis (osteonecrosis is the preferred term
now)
Epidemiology
Incidence
20 000 new cases per year in US and accounts for 10% of THA performed
Demographics
Male>female
Average age of presentation is 35 to 50 years old
Location
Bilateral hip involved in 80% of the time
Multifocal AVN
Disease in three or more different joints
3% of patients with osteonecrosis have multifocal involvement
Risk factors
Direct causes
Irradiation
Trauma
Hematologic diseases (leukemia, lymphoma)
Dysbaric disorder (caisson disease)
Marrow replacing diseases (Gaucher’s disease)
Sickle cell disease
Indirect causes
Alcoholism
Smoking
Hypercoagulable states
Steroids (exogenous/endogenous)
Systemic lupus erythematosus (SLE)
Transplant patient
Virus (CMV, hepatitis, HIV, rubella, rubeola, varicella)
Protease inhibitors (type of HIV medications)
Idiopathic
Pathophysiology
Idiopathic AVN
Intravascular coagulation is the final common idiopathic pathway
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Coagulation of the intraosseous microcirculation  venous thrombosis  retrograde
arterial occlusion  intraosseous hypertension  decreased blood flow to femoral
head  AVN of femoral head  chondral fracture and collapse
AVN associated with trauma
Due to injury of femoral head blood supply (medial femoral circumflex)
AVN rates of specific traumatic 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
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Higher risk of AVN with greater initial displacement and poor reduction
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Decompression of intracapsular hematoma may reduce risk

Quicker time to reduction may reduce risk
Natural history of osteonecrosis of hip
Asymptomatic osteonecrosis
Lesion less than 30% of the area of the femoral head
Remain asymptomatic in most patient (95%) for more than 5 years
Large lesion >50% of the area of the femoral head
83% of patient will become symptomatic
Symptomatic osteonecrosis
Rate of femoral head collapse >85% at 2 years in symptomatic patients (stage 1 or 2)

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Classification
Ficat and Arlet Classification
Classification based on radiographic changes

Steinberg Classification (modification of Ficat classification)

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Presentation
Symptoms
Insidious onset of pain, groin pain on ambulation
Pain with stairs, inclines and impact
Pain common in anterior hip
Physical examination
Mostly normal initially
Advanced stages similar to hip OA (limited motion, particularly internal rotation)
Imaging
Radiograph
Bilateral hip AP and frog leg lateral
Important for diagnosis and classification
Contralateral normal hip x-ray is important as most cases present with bilateral
Patient should be followed up with x-ray if contralateral hip is normal
MRI
Highest sensitivity (99%) and specificity (99%)
Double density appearance
T1: dark (low intensity band)
T2: focal brightness (marrow edema)
Order when radiograph is negative but AVN is suspected
Presence of bone marrow edema on MRI is predictive of worsening pain and future
progression of disease
MRI of the normal hip should also be done to evaluate the asymptomatic hip to detect
early stages of the disease so that treatment can be started early
Bone scan
Technetium-99m uptake is decreased at the very early stage of disease but is variable
or increased at a stage when symptoms occur

Management
Nonoperative
Bisphosphonates
Indicated for precollapse AVN (Ficat 0-2)
Controversial
Some studies shows benefit of preventing collapse
Recent studies shows no benefit of preventing collapse
Weight bearing limitation
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Crutches ambulation or bed rest
Generally ineffective in preventing femoral head collapse
Should be used while waiting for operation in patient that is planned for femoral
head preserving technique to prevent collapse
Surgical
Core decompression with or without bone grafting
Indications
For early AVN, before subchondral collapse occurs, up to Ficat 2A
Reversible etiology
Theory
Core decompression relieves intraosseous pressure due to venous congestion,
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allowing improved vascularity

Technique (traditional core decompression)
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Approach hip through longitudinal midlateral approach (2-3cm) centered over

subtrochanteric region (can do in supine or lateral)
Fascia lata is split in the direction of its fibers
A 3.2mm threaded guide pin is inserted from the lateral cortex towards the head
(necrotic part)
Entry point should not be below the lesser trochanter as it increases
postoperative fracture rate
Overream through the guide pin with an 8mm reamer
Bone graft or bone graft substitute can be placed in the void after core
decompression
Partial weight bearing for 6 weeks or more post op, then only start full weight
bearing
Technique (percutaneous technique)
Multiple small drillings with a 3.2m Steinmann pin is done for decompression
Pros
Simple to perform
Very low complication rate
Does not alter the anatomy therefore does not complicate future arthroplasty
Outcome
Less pain as intraosseous hypertension is reduced
Stimulates healing response via angiogenesis
Less predictable outcome in advanced Ficat stages (2B or 3)
Curettage and bone grafting
Indications
Preferable pre-collapse
Technique
Approach via anterior to prevent disrupting the posterior blood supply to the head
Open window by either one of these two technique
Core track technique (refer traditional core decompression)
Pros: simple technique, avoid surgical hip dislocation and low complication
rate
Lightbulb
Window (2x2cm) through the cortex of the femoral neck-head junction
(anterosuperior) to access the necrotic area of the femoral head and place
bone graft
Pros: direct evaluation of necrotic head
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Cons: risk of femoral neck fracture
Trapdoor
Window through articular surface
Cons: require surgical hip dislocation which may further compromise blood
supply, technical difficulty, iatrogenic cartilage damage
Pros: direct evaluation of cartilage surface and necrotic bone
Necrotic bone is debrided from the femoral head and then packed with bone graft
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Proximal femoral osteotomy

Indications
Only for small (<15%) to medium (<30%) sized lesions in which the lesion can be
rotated away from a weight bearing surface
Young patients where aim is to delay THA
Aim: to move the involved necrotic segment of femoral head from the principal weight
bearing area
Technique
Anterosuperior disease: Transtrochanteric rotational osteotomy
For medial disease: perform varus rotational osteotomy
For anterolateral disease: perform valgus flexion osteotomy
Outcome
Reported success rate of 60-90%
Distorts the femoral head making THA more difficult

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Vascularized free fibular graft

Indications
Precollapse and collapsed AVN in young patient
Reversible etiology preferred
Technique
Remove necrotic area with large core hole
Fibular strut is placed under subchondral bone to help prevent collapse or tamp up
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small area of collapse
Outcomes
Some center demonstrate 80% success at 5-10 year follow up
Less predictable in patients >40 years
Complications
Related to donor site morbidity
Sensory deficit
Motor deficit
FHL contracture
Tibial stress fracture from side graft is taken
Hemiarthroplasty
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Not indicated due to poor outcome in young patient (acetabular erosion – protrusion)
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Total hip resurfacing arthroplasty

not indicated anymore due to
neck tends to fail/fracture
AVN can be extensive beyond the neck
Acetabular cartilage wear
Resurfacing hemiarthroplasty has many failure due to acetabular cartilage wear,
therefore total hip resurfacing arthroplasty is done instead
Indications
In advanced degenerative joint disease with small, isolated focus of AVN
Requires adequate bone to support resurfacing component
Contraindicated in underlying disease process or chronic steroid use causing AVN
(poor bone quality) and renal disease (metal ions from metal on metal implant)
Outcomes
Medium term follow up showing problems with acetabular erosion and pain

Total hip replacement

Indications
Younger patient with crescent sign or more advanced femoral head collapse,
acetabular degenerative disease
Irreversible etiology (chronic steroid use)
Patient >40 with large lesions
Techniques
Cementless cup and stem
Cemented THA has higher failure rate in treating AVN
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Care must be taken while preparing the femur as there are high rates of femoral
canal perforation
Especially in patient with sickle cell disease due to femoral medullary widening
from chronic marrow hyperplasia adjacent to patchy areas of dense sclerosis
causing canal preparation difficult. Perforation rate 4.9-18.2%
Outcomes
In young patients with AVN, there is a higher rate of linear wear of the
polyethylene liner and a higher rate of osteolysis than compared to older patients
Provides good pain relief and function
Hip arthrodesis
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Indications
Only consider in the very young patient in a labor intensive occupation
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Use in patient with hip AVN is limited due to

Arthrodesis is difficult to perform due to necrotic bone
80% of patient has bilateral disease making it not an acceptable alternative

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