|Year : 2002 | Volume
| Issue : 4 | Page : 267-273
Department of orthopaedics, NR Sirear Medical College, Kolkata, India
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|How to cite this article:|
Baksi D P. Avascular necrosis. Indian J Orthop 2002;36:267-73
| Introduction|| |
A vascular necrosis (AVN) has become a subject of interest amongst orthopaedic surgeons only during the last four to five decades. The bones commonly affected are, the femoral head, humeral head, scaphoid, lunate, talus, medial condyle of tibia and capitellum, of which the femoral head is the commonest site.
There are several etiological factors of osteonecrosis of femoral head. They may be traumatic (after femoral neck fractures or dislocations of hip joint), idiopathic, corticosteroid induced, alcohol abuse, following infection, haemoglobinopathy, postirradiation, Caisson's disease, Gaucher's disease and associated with gout. Commonly, the patients belong to third to fifth decades of life. Since the etiopathogenesis is different, the pathomechanics vary from case to case. Though the ultimate fate of the necrotic femoral head is the same, the results of treatment may vary with the etiology.
Diagnosis of AVN femoral head is done by pain around the hip, gradual limitation of motions, radiographic criteria and staging of Ficat and Arlet.  Radionuclide Scintigraphy (99 mTc Di-phosphonate ) can be done especially for diagnosis in the early stages of AVN, CT to detect the early details of bone changes, MRI to record very early marrow necrosis not detectable by CT and tests for haemodynamic functions (intramedullary pressure measurements and venography for vascular stasis.
Staging of AVN
There is no standard unified classification of AVN of femoral head. Proposer for different surgical techniques has utilised different classification scheme for their convenience like Ficat and Arlet  , Marcus - Enneking and Massam  , Steinberg, Heyken and Steinberg  , Arco  . Of the above classifications, Ficat and Arlet classification is simple and practical therefore is in use commonly; however, they do not include those cases of AVN having degeneration of hip joint without collapse of femoral head.
Clinicopathological status of hip joint in AVN femoral head
Patients may present with pain in hip which is due to subarticular increased intravenous pressure in early stages of AVN, marrow oedema, necrosis and also due to increased intracystic pressure associated with degenerative changes of hip in advanced stages of necrosis. In advanced stages, there may be collapse of femoral head, cheilus formation with adhesions around the periphery of femoral head and associated contracture of articular capsule which causes pain due to its stretching effect over the peripheral cheilus. These may produce mechanical derangement resulting in limitation of hip motions.
The natural history of AVN of femoral head shows 75 % to 100% incidence of collapse observed by different workers. ,, There are several treatment options in vogue. We have to select the most suitable one considering the age of the patient, etiological factor, capacity of bone repair, stage of the diseases, associated systemic disease and life style of the people of our country who need squatting habit. Moreover, the surgical technique should be reproducible by an average orthopaedic surgeon, keeping the option open for further salvage procedure or replacement arthroplasty if that modality fails in future.
Bed rest or continuous tractions and prolong period of non-weight bearing have no effect on AVN over final outcome as collapse of femoral head occurred in 68% to 92% of cases following the above treatment. Hence the cicatrization effect of the necrotic zone apart from weight bearing stress may be the reason of collapse. ,,
Use of electromagnetic fields has doubtful role as the good results were reported by Basset et al , while poor results by Steinberg et al. 
Femoral head preserving operations
The object of femoral head preserving operation is to relieve pain in hip, improvement of its limited motions, prevent articular collapse and improvement of shape of deformed femoral head, resulting from limited degree of collapse.
Osteotomies - lntertrochanteric osteotomies e.g. varus osteotomy  , oblique varus rotational (retrotorsion or antetorsion) osteotomy  , displacement osteotomy of McMurray  , valgus osteotomy ,, transtrochanteric anterior rotational (45 0 - 90 0 ) osteotomy  and flexion osteotomy  were all designed to transfer the weight bearing forces from the necrotic area to the cartilage of healthy part of femoral head for spontaneous healing of the necrotic area by hypervascularisation of upper part of femur. 
These operations can produce good results in the early stages (I and II) of necrosis but when collapse has occurred, intertrochanteric osteotomies are not effective and most results are inconsistent and deteriorate rapidly with time. ,, Sugioka anterior rotational osteotomy showed excellent results in 86% cases in 11 years follow up  and successful results were also reported by different Japanese surgeons ,,, but poor results with several complications from difficulty of fixations, delayed union and nonunion were reported from American surgeons. , Poor results as high as 83% cases after Sugioka's procedure may be due to stretching of posterior articular capsules and posterior branch of medial circumflex femoral artery due to anterior rotation of femoral head leading to further AVN. 
Osteotomies being extraarticular procedures fail to rectify the intraarticular mechanical derangement resulting from cheilus around femoral head or marginal adhesions and capsular contractures occurred in advanced stages of AVN to improve hip motions. Moreover, osteotomies may pose problems during THR if needed in future.
Core decompression of the femoral head 
It may be effective in early stages of AVN with 80% - 95% good results but showed unsatisfactory results in advanced stages.  Only 40% good results with higher incidence of fracture and collapse of femoral head , and overall 36% to 57% femoral heads survival in 5 - 10 years have been reported. ,, Therefore, core biopsy without cortical grafting should be discouraged
Use of free non-vascularised bone -grafts
The use of nonvascularised tibial bone graft  or fibular bone graft  may be useful with 75% satisfactory results in the early stages of necrosis but in later stages, the results were poor. ,, Moreover, the satisfactory results in early stages deteriorate with longer follow up. , Subarticular curettage of the necrotic bone and it's replacement by cancellous bone grafts failed to relieve pain or prevent progressive collapse of the femoral head. , The incidence of postoperative collapse was reported to be 39%  and 60%  . Therefore the free bone graft, being another piece of necrotic bone, if placed in necrotic bed, unlikely will prove successful. 
Use of free Cancellous and Vascularised Quadratus Femoris (Q.F.) muscle pedicle bone graft ( MPBG ) 
The combined use of quadratus femoris ( Q.F.) MPBG and free cancellous bone grafts in AVN of femoral head provided good results in early stages of necrosis but poor in advanced stages  . It's discouraging results may be due to ineffective curettage from the posterior approach of the necrotic area predominantly present over anterosuperior aspect of femoral head; addition of free cancellous graft behaving as another piece of necrotic bone and failure to place the Q.F. MPBG directly to the necrotic area because of it's shorter length and its spongy structure providing poor strut effect. This was substantiated by Lee and Rehmatullah  who made histological study of failed femoral head with early idiopathic aseptic necrosis ( Stage I and 11 ) about 42 months after the use of Meyer's treatment protocol as above. They noted the presence of still necrotic bone under the collapsed subchondral bone, the area of cancellous bone grafts showed creeping substitution and their junction with MPBG showed live bone with abundant blood vessels. This observation is of great significance considering the preservation of vascularity and viability of MPBG and discouraging results of the use of free bone grafts alone in the necrotic bed of femoral head.
Use of free cancellous bone and osteochondral allografts ,
In advanced stages (III and IV) of AVN, through Smith Petersen approach after anterior dislocation of the hip, the excision of the collapsed segment and packing of the resultant defect by cancellous bone and replacement of osteochondral allograft showed encouraging results in short term follow up. Moreover, though pain and deformity were initially improved, vascularisation and incorporation of the allografts were poor. 
Drilling and tensor fascia lata/ sartorius muscle pedicle bone grafting 
The cases of osteonecrosis after union of intracapsular fracture or reduction of dislocated hip or from other nontraumatic causes like idiopathic, corticosteroid or alcohol induced cases were treated through anterior approach due to existence of osteonecrotic area predominantly present over antero-superior aspect of femoral head. After curettage of necrotic bones through a slot, multiple drillings of femoral head were done for decompression and facilitation of revascularization of necrotic bone by permitting absorption of dead bone and permeation of vascular granulation tissues through drill holes. Through this approach, TFL graft in adults  and sartorius graft in adolescents47were used having their good vascularity and better strut effects. In advanced stages of AVN, subcutaneous adductor tenotomy and cheilectomy of femoral head are done in the presence of its early collapse and degenerative changes to improve hip motions. However, AVN associated with femoral neck fractures, with absorption of femoral neck were treated through posterior approach due to existence of posterior cortical defect using Q.F. or gluteus medius (G.M.) MPBG, after decompression of femoral head by drilling and packing up the deficient femoral neck with free cancellous bone grafts for osteosynthesis and internal fixation by cannulated cancellous screw. 
Significant postoperative clinical improvement was achieved in early as well as advanced stages of the disease in three to 18.5 years (av. 12.5) follow up, postoperative radiological improvement was obtained in 100% cases of stage I, 86.6% of stage II, 74.7% of stage III and 58.3% of stage IV diseases. Overall clinical improvements having excellent and good results were obtained in 88.7% hips whereas radiological improvement was noted in 75.9% hips. The clinical results did not always correlate with this radiological alterations of the femoral head, since some patients achieved satisfactory clinical scoring even in long term follow up despite the lack of radiological improvement or the presence of 1-2 mm collapse with or without early osteoarthrotic changes in the hip.
Among complications, overall collapse of femoral head occurred in 9.2% and osteoarthrosis in 13.3% cases, whereas in advanced stages of necrosis limitations (Av. 30%) of hip movements were seen in 19% and persistence of painless limp in 16% cases.
Immediate relief of pain in hip was regularly achieved in all stages of necrosis by the release of capsular contracture by anterior capsulotomy, removal of marginal adhesions, relief of capsular stretching effect by cheilectomy, relief of increased subarticular venous pressure in osteonecrosis and intracystic pressure in the presence of osteoarthrosis by multiple drilling and judicious cureftage of the necrotic area. The permeation of granulation tissues into the drilled area growing from the adjacent MPBG, helped in revascularisation of the necrotic area resulting in long lasting pain relief. The above factors, in addition with subcutaneous adductor tenotomy in advanced stages, improved hip motions.
Free cancellous bone grafts combined with vascularised fibular grafts ,,,
The object of the above procedure is to introduce a source of mesenchymal stem cells, provide a vascular supply and strut effect to articular cartilage. This can be done by intra-articular approach by dislocating the femoral head anteriorly , leading to unsatisfactory results due to radical curettage and packing of the large resultant defect with free cancellous bone graft. The other procedure of transtrochanteric approach , by excision or cureftage of the necrotic bones, packing of autogenous cancellous bone chips around vascularised fibular graft and microanastomosis of nutrient fibular vascular pedicle with anterior circumflex femoral vessels are done simultaneously. However, their survival rate at 4.2 years follow up is 89% in Ficat and Arlet Stage II necrosis and 81 % in Ficat and Arlet Stage III 53 and at 5 years follow up, 69% survival rate in Marcus stage II to VI with 31% needing conversion to THR.  Moreover, it showed donor site morbidity with the experience of pain in 11.5% cases, motor deficit in 2.7% and subtrochanteric fracture.  Transtrochanteric approach of the above procedure fails to rectify the intraarticular mechanical derangement, provide inadequate curettage of necrotic area present predominantly in the anterosuperior aspect of femoral head. Moreover, they are technically demanding and if vascular anastomosis fails, they act as nonvascularised bone grafts. 
Vascularised iliac crest graft ,,
Vascularised iliac crest grafting based on deep circumflex iliac artery ,, showed 55 - 74% good results in early ( 1-6 years) follow up , whereas their midterm results (4-14 years) showed 41.6% to 52% good results in Ficat and Arlet II and early Stage III AVN. , Moreover, they are technically demanding and their results were not encouraging, which may be due to torsion or injury of single unsupported vascular pedicle per and postoperatively leading to impaired vascular supply to the femoral head.
Sickle cell disease with AVN
Subarticular injection of acrylic cement in the collapsed portion of femoral head in sickle cell disease with AVN permitted weight bearing in 5 days.  This showed 87% improved results in 5 years follow up. Different treatment modalities in AVN associated with sickle cell disease were tried and their results were reported.  Encouraging result of the use of TFL MPBG graft in sickle cell osteonecrosis were also reported. 
Total Hip Replacement
The cemented THR : showed overall 67% mechanical failure under 30 years age group in contrast to lower failure rate seen in older age group with average 37% failure rate in unilateral cases and 46% in bilateral cases in 7.6 years followup.  However, they produce high rate of loosening in younger individual in long term followup , , possibly due to ongoing necrosis in proximal femur, osteoporosis or osteomalacia, uncontrolled haemoglobinopathy, chronic alcoholism and chronic use of steroid.
In sickle cell disease with AVN THR showed 59% revision rate in 5.5 years follow up due to infection, and early loosening. 
Noncemented THR showed encouraging results in short term follow up like 77.8% excellent result in 6 years , only 6% revision rate in 5 to 10 years followup  and 20.5% failure in 7.6 years.  But their long-term results are yet unknown.
Surface replacement hemiarthroplasty of femoral head may be indicated in stage III or early stage IV AVN with large lesion not amenable to other treatment option except THR. Their short term results were encouraging showing 91 % survival in 5 years follow up, whereas at 10.5 years follow up they showed 62% good or successful results, therefore considered as a successful interim procedure. 
Osteonecrosis of Humeral Head
It is the second most common site following the causes similar to AVN of femoral head. Conservative treatment often succeeds to provide symptomatic relief, otherwise persistently symptomatic cases need curettage and bone grafting or joint replacement.
Osteonecrosis of lunate ( Kienbock's disease)
It is caused by chronic stress or injury. In most of the cases splintage of wrist for 6 to 12 weeks provide relief of pain reducing mechanical stress. If pain persists or flattening of lunate occurs, intercarpal fusion or excision of proximal row of carpus may be considered. Radiocarpal arthrodesis may be undertaken for persisted pain and restricted motions due to osteoarthrosis.
Osteonecrosis of Scaphoid.
Osteonecrosis of scaphoid is mostly due to proximal pole fracture. In persistently painful wrist, the treatment options are removal of entire proximal row of carpal bones or excision of scaphoid and fusion of proximal to distal row.
Osteonecrosis of Talus
Osteonecrosis of talus may be caused by dislocation or fracture of neck of talus or other atraumatic causes and commonly affects posterolateral part of talar dome. The persistently symptomatic cases may be treated by decompression in precollapsed stage, while arthrodesis of ankle is of choice with collapsed talar dome.
| Conclusion|| |
Every femoral head preserving operation gives good results in early stages of AVN and relatively poor in advanced stages. Moreover, good results in early stages may deteriorate during long-term follow up. However, any method which has got good scientific background and gives good results even in long term follow up and easily reproducible by average orthopaedic surgeon, keeping the options open for further salvage or superior modality of treatment should be the procedure of choice based on surgeon's expertise.
A femoral head preserving operation having satisfactory results in long term follow up should be the treatment of choice in younger individuals and THR in elderly where femoral head is badly damaged and in younger patients with multisystem diseases and poor general health. Considering the life style of people of our country who needs squatting habit, decompression of femoral head and TFL muscle pedicle bone grafting in adults and sartorius grafting in adolescents are good option both in early and even in advanced stages of the disease unless the femoral head is badly deformed or collapsed more than 5mm. Considering its technical simplicity compared to the use of other vascularised bone grafts like vascularised fibular or vascular pedicle iliac crest graft, the above method can be recommended in young where AVN is common. However, it is left to the choice of the surgeons and their personal experiences.
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D P Baksi
Department of orthopaedics, NR Sirear Medical College, Kolkata
Source of Support: None, Conflict of Interest: None
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