1. AVASCULAR NECROSIS FEMUR HEAD
new experiments
Ramesh K Sen
MS, DNB Ortho, PhD
Professor, Department of Orthopedics
Postgraduate Institute of Medical Education and Research
CHANDIGARH, INDIA

2. AVASCULAR NECROSIS FEMUR
HEAD-EXPERIMENTS
Diagnostic experiments
• Medical management
•
•
Surgical salvage femur head
•
Surgical nonsalvage options

3. AVN- MRI DIAGNOSIS
MRI T1 Image
signal from ischemic marrow
• Single band like area of low signal
intensity.
•
•
100% sensitivity,98% specificity
MRI - T2 image
•
•
•
Double Line sign
2nd high signal intensity within the
line seen on T1 images.
Represents hyper vascular
granulation tissue

4. MRI IN DIAGNOSIS OF AVN
Results of a rapid screening protocol (imaging
time<1 minute) similar to those of the routine
protocol (an imaging time >7 minutes) for patients
99% sensitive, 98% specific
May DA, Disler DG. Screening for
avascular necrosis of the hip with rapid
MRI: preliminary experience. J Comput
Assist Tomogr.;24:284-7. 2000

5. MRI EVALUATION POST HIP
DISLOCATION WITH DELAYED
RELOCATION
MRI EVALUATION TIME (WEEKS AFTER INJURY)
6
5
4
3
2
1
0
1
3 5
7 9 11131517192123
NORMAL
NUMBER OF WEEKS
AVN
Total 13/30 patients showed AVN changes, In 6
patients spotaneous slow resolution in 2 months

6. HOW EARLY AVN CAN BE
DIAGNOSED ON MRI ?
Traumatic hip dislocation, serial MRI in 14 patients from
injury through 24 months,
5 hips transient within 3 months—4 improved,
3 hips Changes progressed to AVN
Not reliable in first week after injury for ischaemia.
MRI reliable for AVN marrow changes in 4-6 weeks
Poggi JJ, et al Clin Orthop. Oct;(319):249-59 1995
•

7. ISOTOPE SCANNING OF AVN
With SPECT scanning, the presence of cold
spot is indicative of AVN but diagnostic
sensitivity is 58% & specificity is 78%
(Steinberg ME et al 2001)

8. 18
F-Fluoride PET/CT in Avascular Necrosis of the Femoral Head
Shankalzunnrtht• Gavana. t1BBS,'` Anish Bhattachurrn, DRa1. DAR * Rag/iata Kas!tvap, MD.
Ralnesh Ktanar Se n, RMS, PhD. and Bha,trant Rai Alittal.:11D. DNB*
Abstract: Avascular necrosis
REFERENCES
(AVN) of the femoral head is a devastating
disease in young adults. Magnetic resonance imaging is considered the most
sensitive and specific technique in the diagnosis of'this condition. The authors
present an interesting image of'bilateral AVN of the femoral heads diagnosed
on 1817-fluoride positron emission tomography/computed tomography.
1. Ohzono K, Saito M. Takaoka K, et al. Natural history ofnontraumatic avascular
necrosis of the femoral head../ Bone Join Stag Br. 1991;73:68-72.
2. Mont MA, Fairbank AC, Petri M, et W. Core decompression for osteonecrosis of
the femoral head in systemic lupus erythematosus. C lin Orthop Relit Rec. 1997;
334:91-97.
Kes Vlords: "'F-fluoride, PET/CT, avascular necrosis, femur
3. Smith S' Fehring TK, Griffin WL, et al. Core decompression of the osteonecrotic femoral head../ Bone Joint Surg Ant. 1995;77:674-680.
(CYi,, Vucl died 2013.38: e265 e266)
4. Castro FP Jr, Harris MB. Differences in age. laterality, and Steinberg stage at
initial presentation in patients with steroid-induced, alcohol-induced, and idio-
40
1r4p
0
To

9. Oper Tech Orthop 15:273-279 ©
2005
Hip arthroscopy can help
improve overall diagnostic
accuracy and serve as a
direct means of treatment
or adjunct to the
application of more
traditional techniques in
avascular necrosis
management.
•

10. Non-surgical Interventions in AVN
RESTRICTED WEIGHT BEARING
Meta-analysis of protected weight bearing
in 819 patients demonstrated a failure rate of
>80% at a mean of 34 months.
conservative treatment of osteonecrosis
femoral head by protected weight bearing is
not appropriate.
Mont MA, Carbone JJ, Fairbank AC.
Clin Orthop Relat Res.;324:169-78. 1996

11. 1997 early
1997
1997 late
1998
1998
2001
2001

12. Patient restricted
activity & pain 2007
Opts for THR

13. AVASCULAR NECROSIS FEMUR
HEAD-EXPERIMENTS
Diagnostic experiments
• Medical management
•
•
Surgical salvage femur head
•
Surgical nonsalvage options

14. Non-surgical Interventions in AVN
PHARMACOLOGICAL AGENTS
•
Anabolic steroids
Stanozolol (6mg/day) decreases AVN symptoms at
1 year following treatment.
Glueck et al. Am J Hematol.;48:213-20. 1995
•
Enoxaparin
On 60 mg/day for 12 weeks, 89% did not require
surgery Glueck et al CORR;435:164-70 2005
• Iloprost - prostacyclin derivative
a vasodilator, usedul in AVN FH & BMES.
Disch et al,J Bone Joint Surg Br.;87:560-4. 2005

15. Hyperoxygenation
mediated relief of
ischaemia enhances
the fibroblastic,
angioblastic and
osteoclastic activities
•

16. After RPMF treatment, osteogenesis regeneration of
necrotic femoral head markedly improved (micro-CT).
• RPMF could affect various critical aspects in the
course of femoral head necrosis, a promising measure
in the treatment of avn of femoral head, in the early
stage.
•

17. Surgery can be prevented/deferred
in AVN.
•
•
•
Improvement objective clinical
assessments but also in radiological
parameters.
a trial of alendronate for all
patients with early AVN of the hip,
i.e. stages I and II and early stage III
will be beneficial.

18. Non-surgical Interventions in AVN
BISPHOSPHONATES
Increased resorption contributes
to collapse of the femoral
head.
Experimental studies:
Alendronate Inhibits osteoclast
activity & thus curtail bone
resorption.
Tagil et al. in rats Acta Orthop Scand.; 75:756-61. 2004
Bowers et al. in canines. J Surg Orthop Adv.;13:210-6. 2004
Kimet al, in immature pigs. J B J S Am.;87:550-7, 2005.
Clinical studies:
Lai et al, J Bone Joint Surg Am.;87:2155-9. 2005

19. •
ESWT and alendronate produced comparable
result as compared with ESWT without
alendronate in early ONFH. ESWT is effective with
or without the concurrent use of alendronate.

20. AVASCULAR NECROSIS FEMUR
HEAD-EXPERIMENTS
Diagnostic experiments
• Medical management
•
•
Surgical salvage femur head
•
Surgical nonsalvage options
ARCO meeting Chicago March 2013

21. Surgical Interventions in AVN
CORE DECOMPRESSION
Meta-analysis of CD in 1206 hips in 24 studies
84% Ficat-I & 65% Stage-II had successful result.
22 studies: success rate of CD significantly higher than
that of conservative treatment for early-stage disease
(p < 0.05)
Castro FP Jr, Barrack RL.. Am J Orthop.;29:187-94. 2000

22. CD USING PERCUTANEOUS
MULTIPLE SMALL-DIAMETER DRILLING
•
Multiple small drillings with a 3mm Steinman pin to effectuate
the core decompression.
Successful outcomes in:
24/30 Stage I hips (80%;23
patients) had
•
8/15 Stage II hips (57%; 12
patients)
•
Mont MA et al Clin Orthop Relat Res. Dec;(429):131-8, 2004

23. CORE DECOMPRESSION
WITH BMP
Partially purified human BMP combined with
allogeneic antigen-extracted autolyzed human
bone and introduced CD.
At a mean of 53 months, 14/17 hips showed a
clinical success, with HHS of >80 points and no
patient requiring conversion to a total hip
replacement.
Lieberman JR, Conduah A, Urist MR. Treatment of osteonecrosis of the
femoral head with core decompression and human bone morphogenetic
protein. Clin Orthop Relat Res.;429:139-45. 2004

24. GROWTH FACTORS & GENE THERAPY
•
vascular endothelial growth factor (VEGF)
stimulate angiogenesis and promotes healing.
use of a recombinant plasmid pCD-hVEGF165
mixed with collagen for the treatment of an
animal model of osteonecrosis
•
new bone was observed in the channel of the
drill hole and on the surface of the dead
trabeculae.

25. CORE DECOMPRESSION
BONE MARROW AUGMENTATION
Marrow contains
BMP+
Angiogenic factors.
BONE MARROW osteoblast progenitor cells from
pluri-potential connective-tissue stem cells
proliferate to form colonies that express AKP &
subsequently, a mature osteoblastic phenotype

26. Since bone marrow contains
progenitor cells it may be
associated to core
decompression.
It is a simple and easy
adjuvant to core
decompression.

27. In 2003 …..DR PR…
48 years male with
Fracture Dislocation
hip in MVA, reduction
in 2 hours but got MRI
at 8 weeks after injury

28. P R- 8 years FU in 2011

29. AUTOLOGUS BONE MARROW
GRAFTING OF AVN
•
Hernigou et al (2000, 2002, 2004,
2005) Experience of 189 hips.
No control group, surgical
technique variable.
Gangii V et al JBJS Am. Jun; 86A(6):1153-60 2004 Experience of
BMSC+CD in 10 AVN hips, compared
8 controls with CD.

30. BONE MARROW STEM CELL CONC.
•Total
100-180 mL marrow (100
ml Unilateral and 180 for
Bilateral Hip AVN patients)
1.
2.
3.
4.
5.
Ficoll layering on marrow in 1:3 ratio
Centrifuged at speed 400/m for 30 min. at 250C.
Plasma layer aspirated, discarded
BMSC into another sterile tube + PBS buffer
Washed thrice
re-suspension in 2.5 ml buffer.
BMSC content : mononuclear stem cells +
monocytes, lymphocytes, PMNs
(MNC count with CD34+ more than 5X107 )

31. NON-TRAUMATIC AVN
MANAGEMENT CD+BMSC
Idiopathic bil. AVN with 3 months painful hip &
restricted hip ROM

32. E. FU after 18 months of CD+BMSC, MRI
lesion in healing phase, no edema or effusion

33. After 6 years FU in 2011

34. 51 AVNFH randomly divided. group A (25) treated with
CD, group B (26) received autologous BMMNC
instillation after CD. Outcome compared clinically
(HHS), x-ray and MRI, & by Kaplan-Meier hip survival
analysis at 12 & 24 months FU
Clinical score & mean hip
survival better in group B
than in group A (p<0.05).
•

35. BMSC AFFECT AVN HIP ?
Hernigou et al (2005) Instillation of MNC into the
necrotic area in AVN enhances vascularization and
the oxygen flow to the ischemic tissues
Tzaribachev et al (2008) autologous MSCs could
potentially complement AVN treatment by adding
fresh "osteogenic cells" to the healing process.

36. case of a patient with bilateral osteonecrosis of the
femoral head treated with autologous cultured
osteoblast injection.
• Experience is limited to one patient, autologous
cultured osteoblast transplantation appears to be
effective for treating the osteonecrosis of femoral
head.
•

37. CD+ CULTURED OSTEOBLASTS
instillation

38. Biol Bloril.1 Grr•ro;:• 7i•rnn'yhnrt 14:
1081- 1087 (?O/)S) ) 0('M' .-l merica,, Society for Blood ,n
d .11rn•ro
7 rurr+pLiit
rti
;
i
REVIEW
Cell-Based Therapies for Osteonecrosis of the Femoral
Head
CeI Iular- Based Therapy
for Osteonecrosis
B. Jones, 1'3 Tara Seshadri,2'3 Roselynn Krantz,2 Armand Keating, 2,3 Peter C. Ferguson 1'3
CORE DECOMPRESSION WITH MARROW
STEM CELLS
Valerie Gangji, MD, PhDa•*, Jean-Philippe Hauzeur, MD, PhDb
KEYWORDS
• Osteonecrosis • Bone marrow • Stem cell
0-I LI==E HERN GC.,, MD CL `e FP. `,IAN -CM. L'D.
A_EXANDRE -OISNARD. P.O. ALEXIS NOGIER. MD.
nACLO FlLIR?INl. MC. and LID A CE ABR
MD
• Cellular therapy
Treatment of Osteonecrosis of the Femoral Head with Implantation of
Autologous Bone-MIarrow Cells
V'ale:ie Craaj3 and :ear-?_:ippe Hauzeur
j Bone join Surg. Am. 8-.106-111.2005. do::102106 JBJS.D.02662
hoN .
ASPECTS OF CURRENT MANAGEMENT
„•
The use of percutaneous
autologous bone marrow
transplantation in nonunion and
avascular necrosis of bone
P. Hcmigou,
A. Poignard.
0. Manicom,
Bone marow and orthopaedic surgery
Burwell' showed that primitive ostcogcni.
During the development of normal bone in the cells in bone marrow are responsible for much
young child, osteoblasts and then haematopoi- of the biological efficacy of cancdloua bone

39. BMSCs-seeded BBM combined with rhBMP-2 are
capable of improving the quantity and quality of
new bones to grow in the subchondral defects of the
femoral head, and repairing early-stage
osteonecrosis of the femoral head in rabbits.

40. local application of traditional
Chinese medicine, Danshen, the
dried root of Salvia miltiorrhiza,
promotes blood flow and resolves
blood stasis. also provides mechanic
buttress in the weight loading
•
•
minimal invasion surgery for
ischemic necrosis of the femoral
head at Stages I, II and III of ARCO.

41. NON-VASCULARIZED IMPACTION
BONE-GRAFTING
P.S.R. 9 yrs FU
At 18 months
AVN on imaging
R Sen PPT
41

42. NON-VASCULARIZED BONE-GRAFTING
Removing osteonecrotic bone
impacting autogenous cancellous
bone grafts
Lateral approach
Of 28 hips followed for a 42 months Of
18/20 hips survived, successful result
(minimal pain)
70% no progression
Rijnen WH, Gardeniers JW, Buma P, Yamano K, Slooff TJ, Schreurs BW. Treatment of
femoral head osteonecrosis using bone impaction grafting. Clin Orthop Relat
Res.;417:74-83. 2003

43. successful in Ficat and
Arlet stage-III
•
osteonecrosis of the hip
in patients with small- to
medium-sized lesions.
•

44. LIGHT BULB PROCEDURE
2 years PO
At mean 4 years (range, 3-4.5 years), 18/21 hips clinically
successful result (HHS>80 points , no additional procedures).
Mont MA, Etienne G, Ragland PS. Outcome of non-vascularized bone grafting for
osteonecrosis of the femoral head. Clin Orthop Relat Res.;417:84-92. 2003

45. EXPANDABLE DRILLING SYSTEM&
CURRETTAGE WITH BONE GRAFTING

46. FREE FIBULAR GRAFTING

47. survival rate of 59% five years after surgery.
• significant difference (p = 0.002) in survivorship, when
using a clinical and radiological end-point, between
the two grafts, in favour of the tibial autograft.
•

48. TRABECULAR METAL AVN
INTERVENTION
metal tantalum (Trabecular Metal) that’s full of pores.
The rod-shaped implant available in various lengths.
has threads at the end of the rod away from the hip
that screw into healthy bone on the outer edge of the
femur

49. QUADRATUS FEMORIS/TFL
MUSCLE PEDICLE GRAFT
(FU >4 years)

50. •
FU of 10 to 21.5 years
Excellent & good results in
Hospital for Special Surgery
(HSS) score obtained in 100%
of cases in Stage I, 92% in
Stage II and 80.4% in stage III,
with a survivorship of 91% in
Stage II and 82% in Stage III
cases.

51. VASCULARIZED FIBULAR GRAFTING
Vascularized fibula into osteonecrotic femur head

52. VASCULARIZED FIBULAR GRAFTING
11 YEARS
FOLLOWUP

53. •
124 hips, mean FU , 13.9
years; Mean HHS improved
from 72 to 88.
Unchanged radiographs in 37
of 59 hips initially Stage II hips
and 39 of 65 Stage III hips.
Thirteen hips (13 patients)
(10.5%) failed treatment and
underwent total hip
arthroplasty.
•

54. VASCULARIZED ILIAC GRAFTING
•
•
35 operations pedicle iliac bone, 28 patients stage II
13/17 hips no collapse deep circumflex iliac pedicle bone
graft indicated for stage 2 type C-1 necrosis,
Nagoya et al, Predictive factors for vascularized iliac bone graft for non-traumatic
osteonecrosis of the femoral head. J Orthop Sci.;9(6):566-70.
2004

55. BONE GRAFT +
VASCULAR MUSCLE PEDICLE

56. INTER-TROCHANTERIC OSTEOTOMY
Angular osteotomies best results in young active
patients not on corticosteroids,unilateral involvement
with a good preoperative ROM of hip, and a small lesion
without collapse.
96% success at 3-26 years postoperatively
Mont et al (76%) a good or excellent result, and
nine (24%) had a fair or poor result

57. TROCHANTERIC ROTATION
OSTEOTOMY
•
Sugioka rotation osteotomy delays hip degradation
• patients with AVN Stage II disease.
may be a role in selected
patients, difficult to perform and
a high potential for morbidity,
including nonunion
Results variable, with success
rates around 40%
Shannon BD, Trousdale RT. Femoral osteotomies for avascular necrosis of the
femoral head. Clin Orthop Relat Res.;418:34-40. 2004

58. OSTEOTOMY+VASCULARIZED GRAFT
•Conversion
to
endopros
avoided in all except one.
•For
advanced and
extensive
osteonecrosis of the femoral head,
especially in young patients, to preserve
the joint.
•Relatively complex procedure.

59. CEMENTATION OF FEMORAL HEAD
relying on the fact that the cartilage cells will survive
because the articular cartilage is nourished by the
synovial fluid
Ph. HERNIGOU, D. GOUTALLIER :, Ed. J. Arlet, B. Mazieres,
Springer Verlag, 353-355.
1990

60. CEMENTATION OF FEMORAL HEAD
Wood et al. treated 19 patients (20 hips) with open
reduction augmented with methyl methacrylate
cement and followed them for 6 months to 12
years.
3 patients had a conversion to a THR
The long-term results of this procedure are
unknown.
Wood ML, McDowell CM, Kerstetter TL, Kelley SS. Open reduction and cementation
for femoral head fracture secondary to avascular necrosis: preliminary report. Iowa
Orthop J. 2000;20:17-23.

61. AVASCULAR NECROSIS FEMUR
HEAD-EXPERIMENTS
•
Diagnostic experiments
•
Medical management
•
Surgical salvage femur head
•
Surgical non-salvage options

62. TOTAL HIP ARTHROPLASTY
AVN vs. OA as Etiology
Failure rate in AVN higher than OA group
(33%);
•
1, Bilateral Occurrence of the disease with
bilateral THA
2, Extensive bone necrosis
•
Femoral component loosening more
frequently in the ON (28%) than in the OA
group (5%).

63. TOTAL HIP ARTHROPLASTY
FOR OSTEONECROSIS
•
Meta-analysis
- Before 1990
•
83% survival
- After 1990
•
97% survival
•
Second generation cementing techniques
•
Proximally coated femoral stems

64. MANY CHOICES OF BEARINGS
Metal on polyethylene
• Metal on highly cross linked
polyethylene
• Metal on metal
• Ceramic on ceramic
• Ceramic on metal
• Ceramic on polyethylene
•
Which is better for osteonecrosis??

65. TOTAL HIP ARTHROPLASTY
•
Non cemented acetabular
component
•
Porous-coated components
•
THA reliable treatment for
- patients >45 years of age
- In patients with post-traumatic
necrosis

66. SURFACE ARTHROPLASTY
Resurfacing of the femoral head successful interim
procedure for Ficat and Arlet stage-III or early
stage-IV disease
HUNGERFORD et al JBJS 80:1656-64 (1998)

67. PREVENTION OF AVN
STATIN THERAPY
Patients on steroids on mean of 7.5 years
(minimum 5 years), also given lipid clearing agents
that reduce lipid levels.
Osteonecrosis in only 3 (1%) of 284 patients
who were taking high-dose corticosteroids + statin
drugs
Statins might offer protection against AVN
when corticosteroid treatment is necessary
Pritchett JW. CORR ;386:173-8 2001

68. A

69. Thank You