Avascular necrosis of hip: Difference between revisions

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==Background==
==Background==
Can be simplified to traumatic and nontraumatic causes that lead to an insult to the blood supply to the bone. The ischemia causes death of osteocytes and bone marrow which will eventually lead to necrosis and collapse of the dead segment.
[[File:Osteonecrosis of Hip.jpg|thumb|Kupe MD. Hip Fracture. http://drkupe.blogspot.com/2011/03/hip-fracture.html. Accessed July 31, 2016.]]
[[File:Osteonecrosis of Hip.jpg|thumb|Kupe MD. Hip Fracture. http://drkupe.blogspot.com/2011/03/hip-fracture.html. Accessed July 31, 2016.]]
Traumatic and nontraumatic causes can lead to an insult to the blood supply of the joint. The ischemia causes death of osteocytes and bone marrow that leads to necrosis and eventual collapse of the dead segment.


==Etiologies==
===Epidemiology===
*Traumatic causes
*Estimate of 10,000 to 20,000 new cases per year
**Femoral neck fracture/Dislocation
*Responsible for about 10% of all total hip replacements
*Patients typically diagnosed before 40 years of age


*Non-traumatic causes
===Etiologies<ref>*JONES PHD, L. C. AND MONT MD, M. A. Osteonecrosis (avascular necrosis of bone) In-text: (Jones PhD and Mont MD) Your Bibliography: Jones PhD, Lynne C and Michael A Mont MD. "Osteonecrosis (Avascular Necrosis Of Bone)". UpToDate. N.p., 2016. Web. 31 July 2016.</ref>===
**Use of Corticosteriods, Alcohol, Tobacco
'''Traumatic causes
**Systemic Lupus Erythematosus
*[[Femoral neck fracture]]/[[Hip dislocation|dislocation]]
**Sickle Cell Disease
'''Non-traumatic causes'''
**Chronic Kidney Disease
*Use of [[corticosteroids]], [[alcohol]], tobacco
**Pancreatitis
*[[Systemic lupus erythematosus]]
**Radiation therapy
*[[Sickle cell disease]]
**HIV
*Chronic Kidney Disease
**Caisson Disease aka Dysbarism
*[[Pancreatitis]]
**Legg-Calve-Perthes disease
*Radiation therapy
**Idiopathic
*[[HIV]]
*Caisson Disease (aka Dysbarism)
*[[Legg-Calve-Perthes disease]]
*Idiopathic


==Clinical Features==
==Clinical Features==
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==Differential Diagnosis==
==Differential Diagnosis==
*Acute Fracture
{{Hip pain DDX}}
*Acute Disclocation
*Septic Joint
*Synovitis
*Musculoskeletal insult


==Evaluation==
==Evaluation==
[[File:Osteonecrosis femur 1.jpg|thumb|Plain XR Osteonecrosis Femur by JMarchn(own work)]]
[[File:Osteonecrosis MRI femur 2img.jpg|thumb|MRI Osteonecrosis Femur by JMarchn (ownwork)]]
*Plain XR is poorly sensitive in early stages, as low as 41%
*Plain XR is poorly sensitive in early stages, as low as 41%
*Radiographic changes may be delayed by years
**AP and Frog leg views
*MRI ~90% sensitivity and specificity
*MRI ~90% sensitivity and specificity
**Best test
*Bone Scan (aka Bone Scintigraph)
**May show evidence of early bone ischemia
==Management==
*Nonsurgical
**Considered ineffective at stopping progression of ischemia
**Bedrest, limit weightbearing, pain control
*Medications
**Bisphophonates, vasodilators, and [[Anticoagulants|anticoagulants]] have been used but efficacy has not yet been proven
*Surgical
**Total Join Replacement
**Unfortunately, patients with osteonecrosis have an increased failure rate of the procedure.
*Ongoing research for treatment
**Joint preserving operations, Bone marrow decompression therapy, vascularized and nonvascularized bone grafts, Bone marrow grafting, and Osteotomy


==Disposition==
==Disposition==
*Initial supportive care until later stages of disease
It is vital to order medical and orthopedic referrals for evaluation of comorbidities and evaluation of joint in the emergency department.
*Orthopedic consultation for repeat imaging and risk stratification for surgical treatment
*Progression to subchondral collapse if the diagnosis is missed and untreated
**67% in asymptomatic patients
**Greater than 85% in symptomatic patients
*In one study by the American Academy of Orthopaedic Surgeons, early detection and treatment with core decompression has shown to prevent the need for total hip replacement.
 
==See Also==
*[[Hip pain]]


==References==
==References==
*JONES PHD, L. C. AND MONT MD, M. A. Osteonecrosis (avascular necrosis of bone) In-text: (Jones PhD and Mont MD) Your Bibliography: Jones PhD, Lynne C and Michael A Mont MD. "Osteonecrosis (Avascular Necrosis Of Bone)". UpToDate. N.p., 2016. Web. 31 July 2016.
<references/>
*Kelly JD et al. Femoral head avascular necrosis treatment & management. Aug 16, 2015. http://emedicine.medscape.com/article/86568-treatment#showall.
*Kelly JD et al. Femoral head avascular necrosis treatment & management. Aug 16, 2015. http://emedicine.medscape.com/article/86568-treatment#showall.
*Miller MD M, Fisher MD S, Foran J. Osteonecrosis of the Hip. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00216. Accessed August 2, 2016.
*Stoica Z et al. Imaging of Avascular Necrosis of Femoral Head: Familiar Methods and Newer Trends. Curr Health Sci J. 2009 Jan-Mar; 35(1): 23–28.
*Stoica Z et al. Imaging of Avascular Necrosis of Femoral Head: Familiar Methods and Newer Trends. Curr Health Sci J. 2009 Jan-Mar; 35(1): 23–28.
 
*Wainwright A. Legg-Calve-Perthes disease diagnostic tests - Epocrates online. Epocrates. https://online.epocrates.com/diseases/75134/Legg-Calve-Perthes-disease/Diagnostic-Tests. Accessed July 31, 2016.


[[Category:Orthopedics]]
[[Category:Orthopedics]]

Latest revision as of 19:11, 13 May 2021

Background

Kupe MD. Hip Fracture. http://drkupe.blogspot.com/2011/03/hip-fracture.html. Accessed July 31, 2016.

Traumatic and nontraumatic causes can lead to an insult to the blood supply of the joint. The ischemia causes death of osteocytes and bone marrow that leads to necrosis and eventual collapse of the dead segment.

Epidemiology

  • Estimate of 10,000 to 20,000 new cases per year
  • Responsible for about 10% of all total hip replacements
  • Patients typically diagnosed before 40 years of age

Etiologies[1]

Traumatic causes

Non-traumatic causes

Clinical Features

  • Limp
  • Limited range of motion of joint, both active and passive
  • Pain: Knee, Thigh, and/or Groin
  • Wasting of local musculature
  • Asymmetric leg length

Differential Diagnosis

Hip pain

Acute Trauma

Chronic/Atraumatic

Evaluation

Plain XR Osteonecrosis Femur by JMarchn(own work)
MRI Osteonecrosis Femur by JMarchn (ownwork)
  • Plain XR is poorly sensitive in early stages, as low as 41%
    • AP and Frog leg views
  • MRI ~90% sensitivity and specificity
    • Best test
  • Bone Scan (aka Bone Scintigraph)
    • May show evidence of early bone ischemia

Management

  • Nonsurgical
    • Considered ineffective at stopping progression of ischemia
    • Bedrest, limit weightbearing, pain control
  • Medications
    • Bisphophonates, vasodilators, and anticoagulants have been used but efficacy has not yet been proven
  • Surgical
    • Total Join Replacement
    • Unfortunately, patients with osteonecrosis have an increased failure rate of the procedure.
  • Ongoing research for treatment
    • Joint preserving operations, Bone marrow decompression therapy, vascularized and nonvascularized bone grafts, Bone marrow grafting, and Osteotomy

Disposition

It is vital to order medical and orthopedic referrals for evaluation of comorbidities and evaluation of joint in the emergency department.

  • Progression to subchondral collapse if the diagnosis is missed and untreated
    • 67% in asymptomatic patients
    • Greater than 85% in symptomatic patients
  • In one study by the American Academy of Orthopaedic Surgeons, early detection and treatment with core decompression has shown to prevent the need for total hip replacement.

See Also

References

  1. ↑ *JONES PHD, L. C. AND MONT MD, M. A. Osteonecrosis (avascular necrosis of bone) In-text: (Jones PhD and Mont MD) Your Bibliography: Jones PhD, Lynne C and Michael A Mont MD. "Osteonecrosis (Avascular Necrosis Of Bone)". UpToDate. N.p., 2016. Web. 31 July 2016.
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