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Avascular Necrosis of the Femoral Head

Avascular Necrosis Femoral Head

Avascular necrosis of the femoral head (AVNFH) is a condition that involves osteonecrosis of the femoral head, due to regional ischemia. It may be caused by trauma or other non-traumatic pathologies, and may ultimately lead to a collapse of the femoral section that has suffered osteonecrosis.


Presentation

Avascular necrosis of the femoral head (AVNFH) is a pathological condition that is otherwise referred to as osteonecrosis of the femoral head or hip osteonecrosis, is more commonly diagnosed amongst individuals aged 20 to 40 and does not tend to subside spontaneously [1].

It is a disorder that usually develops insidiously and does not produce symptoms at the initial stage. Radiating pain that extends to the ipsilateral buttock or knee is frequently reported in symptomatic patients, alongside restricted hip mobility. Particular movements, such as an intense internal rotation, or weight-bearing, can exacerbate the pain. Bilateral participation of the femoral heads has been documented, although the most common presentation involves unilateral involvement [2]. As the disease progresses, pain is aggravated; it eventually appears both when the patient moves and at rest. Limping may be present as well. Accompanying symptoms include tenderness in the region of the hip and a deformed joint with muscle wasting in severely progressed stages. The vast majority of individuals affected by AVNFH who have not received treatment in time appear with a collapse of the head of the femur [3] [4] [5].

Weight Gain
  • Mechanical stress, due to a difficult labour or excessive weight gain during the last trimester of pregnancy, may be another aetiological factor.[ncbi.nlm.nih.gov]
  • Case report: A 36-year-old female, investigated for right leg pain, reported rapid weight gain, easy bruising and secondary amenorrhea.[endocrine-abstracts.org]
  • The patient reported weight gain, secondary amenorrhoea of 2year duration and a recent onset of facial hirsutism.[edmcasereports.com]
Erythema
  • In addition, the patient reported morning stiffness which lasted for 30 minutes but had no symptoms of arthritis, such as swelling, erythema, or local warmth in any joint, including the right hip.[archivesofrheumatology.org]
Hip Pain
  • A 1-year-8-month-old boy with mucocutaneous lymph node syndrome (Kawasaki disease) complained of left hip pain. Radiographic examination revealed avascular necrosis of the femoral head.[ncbi.nlm.nih.gov]
  • This is a diagnosis that should be considered in patients with prostate cancer who present with hip pain in the absence of biochemical evidence of disease progression.[ncbi.nlm.nih.gov]
  • Hip pain began 5 months postoperatively. Roentgenograms revealed rapidly progressive avascular necrosis in both hips.[ncbi.nlm.nih.gov]
  • A 9-year-old girl presented to the emergency room complaining of right hip pain that occurred after a pedestrian car accident.[ncbi.nlm.nih.gov]
  • The findings in these cases and other reports associating AVN with skeletal dysplasia should encourage treating physicians to analyze carefully a sudden increase in hip pain or rapid radiographic development of femoral head collapse in a child with a[ncbi.nlm.nih.gov]
Limping Gait
  • The clinical manifestations of ANFH, including pain on exertion, limping gait, and discrepancy in leg length, cause considerable disability.[genome.jp]
Suggestibility
  • Most studies suggested a positive short-term efficacy of alendronate treatment in reducing pain, improving articular function, slowing of bone collapse progression, and delaying the need for THA for adult AVN patients.[ncbi.nlm.nih.gov]
  • The severe parallel evolution of the small and large joint lesions and the late appearance of osteonecrotic changes in our patients suggest that avascular osteonecrosis is related to the osteoarticular progression of the longstanding SS.[ncbi.nlm.nih.gov]
  • This has been quantified and it is suggested that a loss of osteocytes is perhaps one of the earliest lesions leading to established avascular necrosis.[ncbi.nlm.nih.gov]
  • We have examined physiologic and anatomic factors in this specific disease syndrome, which suggest that this may be the preferred method of treatment.[ncbi.nlm.nih.gov]
  • It is suggested that clinical trochanteric bursitis, especially when refractory to local corticosteroid treatment, may be the initial sign of hip disease.[ncbi.nlm.nih.gov]

Workup

The workup involved in a potential case of AVNFH includes plain hip radiographs and a magnetic resonance imaging scan (MRI scan) of the area. Laboratory evaluation is of no diagnostic value, and, even though a biopsy can ascertain the diagnosis, it is not commonly required.

The radiographic depiction of the presumably affected hip is the first step in the evaluation process of patients who report pain in the femoral region and are in risk for AVNFH [6]. Plain anteroposterior and frog-leg lateral images are obtained in order to assess a potential AVNFH. Subtle lucencies, sclerotic or cystic lesions do raise suspicion for an osteonecrotic state, in which case an MRI is performed [6]. The latter is more sensitive in the initial phase, when a plain radiograph may be inconclusive [7].

In general, AVNFH is classified with the Ficat and Arlet and the Steinberg University of Pennsylvania systems [8]. The former utilizes radiographs, MRI findings and patient symptoms to categorize the condition [9]. A more recent classification system is that of the Association Research Circulation Osseous (ARCO), which proposes that plain radiographs, MRI scans, and histology should all be used in order to produce an accurate classification status. Computerized tomography scans (CT scans) can be performed in the evaluation process, but not in a diagnostic sense. They are used to facilitate surgical planning and to illustrate the severity of a potential femoral head collapse [6].

Ischemic Changes
  • The period for complete radiographic recovery of group I ischemic changes was between 2 to 4.5 years. Preoperative mean AA values of both groups were similar.[ncbi.nlm.nih.gov]
  • We suspect that arteritis, aneurysm, or subsequent thrombosis, which are histopathologically the main lesions in mucocutaneous lymph node syndrome, may induce ischemic changes in the femoral head.[ncbi.nlm.nih.gov]

Treatment

  • In the other 8 cases, a total hip arthroplasty (THA) was chosen as the initial treatment option, with 3 of these patients in Ficat stage III and 5 in Ficat stage IV.[ncbi.nlm.nih.gov]
  • The larger both volumes are, the more likely it is that treatment will fail. In patients with remaining necrosis of less than 1000 mm(3), no treatment failure was observed.[ncbi.nlm.nih.gov]
  • The use of stem cells (SC) for the treatment of AVN of the FH has been proposed.[ncbi.nlm.nih.gov]
  • Closed intramedullary shortening has become a popular treatment method for limb-length inequality in adolescents.[ncbi.nlm.nih.gov]
  • Thus, the intravenous infusion of cervus and cucumis polypeptides was a safe, effective treatment for ANFH.[ncbi.nlm.nih.gov]

Prognosis

  • More recent data have shown that MR imaging may improve staging, investigate radiologically occult collapse, depict other causes of disability and pain, assess prognosis, and evaluate treatment.[ncbi.nlm.nih.gov]
  • Recognition of true AVN, in contrast to the gradual evolution of head shape change in typical skeletal dysplasia, may change treatment recommendations and prognosis.[ncbi.nlm.nih.gov]
  • If the causal genes of avascular necrosis of the femoral head are found, they may be used for early detection, prognosis prediction, and genomic treatment of avascular necrosis of the femoral head in the future. Copyright 2011, SLACK Incorporated.[ncbi.nlm.nih.gov]
  • . - prognosis: - in general, patients with confirmed AVN have a 70-80% chance of collapse after 3 years; - in the series of 72 hips (general population) w/ MRI changes c/w AVN (followed by Ito H, et al (1999)), 64% became symptomatic; - necrotic lesions[wheelessonline.com]

Etiology

  • Discrepancies regarding dose of SC, AVN etiology and disease severity were present.[ncbi.nlm.nih.gov]
  • In most cases, however, the etiology is unclear and generally described in the orthopedic literature in ambiguous terms. Radiologically, the femoral head ossification center may be condensed, deformed or fragmented.[ncbi.nlm.nih.gov]
  • BMSCs were isolated from 20 ANFH patients divided into four groups according to etiology, and four donors with femoral neck fractures.[ncbi.nlm.nih.gov]
  • The etiology of the condition is understood in only 75% of cases. There have been no prior reports of this condition following lumbar spine surgery carried out under hypotensive anesthetic.[ncbi.nlm.nih.gov]
  • Abstract Avascular necrosis of the femoral head is an illness with a controversial etiology, the trigger event being the suppression of blood flow to the femoral head.[ncbi.nlm.nih.gov]

Epidemiology

  • Epidemiology References: [1] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • ANFH is a common disease in China [3], but accurate epidemiological data are unavailable. This disease frequently occurs in adult patients between the ages of 20 and 50 years old [4].[journals.plos.org]
  • Epidemiology Frequency United States AVN of the femoral head is a debilitating disease that usually leads to osteoarthritis of the hip joint in relatively young adults (mean age at presentation: 38 y).[emedicine.medscape.com]
  • Introduction Clinical definition reduced vascular sup ply to the bone resulting in progressive and painful degeneration of the bone also termed osteonecrosis Epidemiology incidence typically occurs in the anterolateral femoral head demographics dependent[medbullets.com]
  • EPIDEMIOLOGY  10-25% of traumatic hip dislocations, risk with duration.  Non displaced femoral neck fractures 10%.  Displaced femoral neck fractures 15-50%. 6.  True incidence of atraumatic AVN unknown but 518% of THR’s performed in US are for AVN[slideshare.net]
Sex distribution
Age distribution

Pathophysiology

  • The temporal association in this instance implicates a pathophysiologic relationship between the development of ALL and necrosis.[ncbi.nlm.nih.gov]
  • On this basis, we propose to study the pathophysiological mechanism(s) of inherited and sporadic ANFH.[clinicaltrials.gov]
  • The pathophysiology of avascular necrosis of the femoral head has not been completely accounted for. In some patients there has clearly been a direct cause (trauma, radiation,..), while in others the pathophysiology is still uncertain.[physio-pedia.com]
  • American Volume 88 1117 – 1132 . ( doi:10.2106/JBJS.E.01041 ) Search Google Scholar Export Citation Glueck CJ Freiberg R Tracy T Stroop D Wang P 1997 Thrombophilia and hypofibrinolysis: pathophysiologies of osteonecrosis .[edmcasereports.com]
  • Litchmann proposed a pathophysiological model of leukostasis, based on the rheological consequences of hyperleukocytosis.[kjim.org]

Prevention

  • Because hip arthroplasty in the younger population is prone to early wear and failure, it is paramount to prevent collapse once osteonecrosis is detected.[ncbi.nlm.nih.gov]
  • It is important to recognise the coexistence of these two pathologies, so as to avoid a delay in diagnosis and prevent significant morbidity and mortality.[ncbi.nlm.nih.gov]
  • In the patient with risk factor(s) for avascular necrosis that diagnosis should be considered and evaluated with appropriate studies, such as magnetic resonance imaging, to prevent weight bearing at an early stage and permit possible surgical decompression[ncbi.nlm.nih.gov]
  • […] changes characteristic of avascular necrosis of the femoral head frequently do not appear for several months after onset of symptoms, it may be difficult to diagnose this condition in its early stages and then institute therapeutic measures designed to prevent[ncbi.nlm.nih.gov]
  • CONCLUSIONS: The attention of physicians treating SCD patients must also be drawn to the possibility of ANFH in order to prevent or avoid this disastrous complication, especially in younger patients presenting with frequent hemolytic crises.[ncbi.nlm.nih.gov]

References

Article

  1. Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. Current concepts on osteonecrosis of the femoral head. World J Orthop. 2015 Sep 18; 6(8): 590–601.
  2. Boettcher WG, Bonfiglio M, Hamilton HH, Sheets RF, Smith K. Non-traumatic necrosis of the femoral head. I. Relation of altered hemostasis to etiology. J Bone Joint Surg Am. 1970;52:312–321.
  3. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am. 2006;88(5):1117–1132.
  4. Erken HY, Ofluoglu O, Aktas M, Topal C, Yildiz M. Effect of pentoxifylline on histopathological changes in steroid-induced osteonecrosis of femoral head: experimental study in chicken. Int Orthop. 2012;36(7):1523–1528.
  5. Floerkemeier T, Lutz A, Nackenhorst U, et al. Core decompression and osteonecrosis intervention rod in osteonecrosis of the femoral head: clinical outcome and finite element analysis. Int Orthop. 2011;35(10):1461–1466.
  6. Murphey MD, Roberts CC, Bencardino JT, Appel M, Arnold E, Chang EY, et al. ACR Appropriateness Criteria Osteonecrosis of the Hip. J Am Coll Radiol. 2016 Feb. 13 (2):147-55.
  7. Lieberman JR, Berry DJ, Mont MA, et al. Osteonecrosis of the hip: management in the 21st century. Instr Course Lect. 2003;52:337–355.
  8. Musso ES, Mitchell SN, Schink-Ascani M, Bassett CA. Results of conservative management of osteonecrosis of the femoral head. A retrospective review. Clin Orthop Relat Res. 1986;(207):209–215.
  9. Jawad MU, Haleem AA, Scully SP. In brief: Ficat classification: avascular necrosis of the femoral head. Clin Orthop Relat Res. 2012;470:2636–2639.

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Last updated: 2019-07-11 19:59