Name: Arthroscopic Treatment of Avascular Necrosis (AVN) of the Femoral Head
Uploaded: 2016-03-04T00:00:00Z
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VPT1-00618-EN | B | Arthroscopic Treatment of Avascular Necrosis (AVN) of the Femoral Head

Thomas Youm

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Arthroscopic Treatment of Avascular Necrosis (AVN) of the Femoral Head

When I first implemented this procedure, my indications for this type of surgery was osteonecrosis of the femoral head, in conjunction with a intra-articular pathology that's addressable by hip arthroscopy, which includes loose body labral tears, femoral acetabular impingement, ligamentum teres rupture, Energel lesions, instability, snapping hip, and extra articular disorders, as well as including trochanteric disorders of greater trochanteric bursitis and gluteus medius tears. Initially, this procedure was designed to address incidental and concurrent avascular necrosis lesions in patients who had hip pain and arthroscopically addressable pathology, such as MRI and labral tears. However, I feel that this procedure is also very useful for isolated avascular necrosis of the femoral head. The advantages of a hip of an arthroscopic assisted hip procedure is that you can diagnose and treat concurrent pathology of the hip, especially if the patients present with pain. We know that MRIs have poor predictive positive predictive value as far as diagnosing delamination associated with FAI. You can confirm that the head is not penetrated by a cord decompression reaming with direct visualization with the arthroscope. He can also insert the scope into the core decompression tunnel to visualize the necrotic AVN lesion. And you have precise staging of the avascular necrosis. You can detect early collapse and damage when you look at it. Arthroscopically. So avascular necrosis or aseptic necrosis of the femoral head typically occurs in patients between 20 and 50 years. The mean is 38 years. It's the same age presentation as femoroacetabular impingement. It's a disease of impaired osseous blood flow. It could be traumatic when you have a displaced femoral neck fracture or hip dislocation. And also non-traumatic. There is an associated with steroids, alcohol abuse, sickle cell anemia, etc. the pathophysiology that's most commonly accepted the femoral head Microcirculation is occluded by intravascular thrombi. There's an extravascular. Compression. Osteonecrosis or bone death occurs after ischemia and the repair process. The dead bone is replaced with new bone. That's called creeping substitution, but the repair is not complete in large lesions. The dead bone fractures, it collapses. That's what produces a crescent sign on X-rays. The femoral head eventually flattens, causes increased stress on the cartilage and eventual degenerative joint disease. There are various staging systems. One is described by Ficat and Arlet. I highlighted in red the important stage one and stage two. That means this is pre collapse of the femoral head. And this is usually when femoral head core decompression is indicated. University of Pennsylvania staging had six stages. Stage six being the most advanced. I also highlighted in red stages 0 to 2 which is pre collapsed stages when it once again cord decompression may be indicated. How do we diagnose avascular necrosis. History. It's typically in a traumatic hip pain. You want to look for associated risk factors in the history, such as steroid use. Physical exam. You may find groin pain, positive impingement test, decreased range of motion. There may be some clicking in the hip, especially if there's a collapsed necrotic fragment. You want to check for Bilaterality of symptoms in 40 to 80% of cases. Avascular necrosis occurs in both hips, and if there's no associated risk factors for AVN, the presentation may actually be identical to that of femoroacetabular impingement and labral tears. So the indications you may have a patient with hip or groin pain, plus or minus mechanical symptoms. Symptoms you have findings of Phi on x rays with cam and pencil spurs. Your MRI may show a labral tear. Cartilage delamination with pre-collapse osteonecrosis of the hip. The osteonecrosis must be pre collapsed for cord decompression to work, which means there must be no crescent sign. The osteonecrosis is likely silent and asymptomatic because it's early, and the contralateral hip may have the same early stage AVN may be asymptomatic. The FAI and labral tears in these situations tend to be what the symptomatic pain comes from, and the early AVN may be clinically silent. First case I have a 30 year old male with nine months of left hip pain after a twisting injury while skiing. On physical exam, he had pain in his groin with a positive impingement and positive Faber test. He had no prior pain and no pain in the contralateral hip. Activity modification and physical therapy led to no improvement. These are his AP X-rays. These are done. Lateral X-rays 45 degrees done. X-rays. This is an MRI of his hip showing a avascular necrosis lesion of the femoral head, and also a lesion of the labrum with a labral tear. This is a sagittal slice showing an anterior location of the avascular necrosis. Patient underwent a diagnostic left hip injection and the pain resolved. Bilateral hip AVM was diagnosed on MRI. Patient had acute left hip pain after skiing with a labral tear and X-ray. Findings of the contralateral right hip where a patient had silent Ava and was asymptomatic and not painful, so therefore patient underwent left hip arthroscopic surgery with labral repair and pincer resection and concurrent cord decompression, and you can see the post-op X-rays with the cord decompression tract on the left hip. The second case is a 4040 year old male who developed right hip pain from running. Symptoms persisted despite 12 months of non-operative treatment. Mri showed a right lateral tear with bilateral AVM. The contralateral left hip was clinically silent, no pain. He improved with a diagnostic injection on the right hip. He had an impingement sign and Faber test on physical exam. These are his AP X-rays and done 45 degree x rays where you see avascular avascular necrosis. The patient underwent right hip arthroscopic labral repair with pincer resection and cord decompression. Six months later, patient underwent left hip diagnostic arthroscopy with cord decompression despite being asymptomatic. To prevent the progression of AVN, there is no labral tearing on the left hip. These are his post-op x rays demonstrating the cord decompression tract. So why do we need to decompress an asymptomatic avascular necrosis of the hip month and Jbj's in 2010 looked at 16 studies where he found 664 asymptomatic hips with AVN. Of those hips, 59% or 394 hips progressed to symptoms are collapsed. Small or medial lesions collapsed less than 10% of the time. Recommended treating lesions that involve lateral two thirds of the weight bearing femoral head and occupy greater than 25% of the femoral head. So the results of core decompression are good. The goals are to decompress the interosseous pressure to restore normal vascular flow and alleviate pain. Been randomized trial including Stulberg, which shows 70% success in non collapsed lesions. Mont did a review in 1996 of 42 studies and 1200 hip core decompression. 71% had good results. So to conclude this core decompression change the natural history of avascular necrosis of the hip. There are too many differences among studies to determine the true success rate of core decompression to does adding biologics, op1, growth factors, bone marrow aspirate, etc. improve clinical results? It remains to be seen, however, there is a trend for success, especially in clinical tests as well as in laboratory tests for success. As far as cartilage healing and bone healing, core decompression is effective for pre-collapse osteonecrosis of the hip and untreated, asymptomatic avascular necrosis of the hip can progress to symptomatic avascular necrosis, so all but the smallest avian lesions should be treated regardless of symptoms. Patients with AVN and Fe are similar in age of presentation. Bilateral bilaterality examine symptoms, and AVN and Fe or labral tears can be simultaneously treated with hip arthroscopy. Concerns for the future. Will traction associated with hip arthroscopy have any adverse effect on the core decompression, and this will be further elucidated by clinical outcome studies in the future.

Arthroscopic Treatment of Avascular Necrosis (AVN) of the Femoral Head

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