Algorithm 5 for OSTEONECROSIS OF FEMORAL HEAD

OSTEONECROSIS OF FEMORAL HEAD

Deformities not characteristic and with progression leads to secondary OA , movements are also lost early .

Always give diagnosis as a differential .

Findings

 Young patient

Flexion deformity

Adduction deformity

IR/ER

Special tests

Trendelenburg test

Thomas

D/D

TB Hip (with restriction of movement )

Transient Osteoporosis of hip in females

Primary OA

Old Perthes disease

Old Femoral Head fracture , secondary OA

Monoarticular Rheumatoid

Why Ostonecrosis

Single joint involvement

No history of trauma

Insidious onset , slow progression

No constitutional symptoms

Drformities don’t match with stage of TB

Even in stage III , movements fairly preserved.

Diagnostic criteria for Osteonecrosis of hip

Japanese Investigating Committee

Major

            There shouldnot be any joint space narrowing or acerabular changes for 1-3 to be positive.

1 radiological (depression on head , demarcating sclerosis on head , crescentic sign )

2 bone scan (cold in hot )

3 MRI (low signal intensity band on T1 image )

4 Histology

Minor

1 Radiological (depression on head , joint space narrowing , cystic lucency , mottled sclerosis , flattening of superior portion of femoral hea )

2 Bone scan (cold or hot )

3 MRI (Homogenous /inhomogenous low signal intensity without a band pattern )

4 symptoms (hip with weight bearing )

5 history of corticosteroid

Definitive Osteonecrosis >/=  2 major positive criteria

Probable Osteonecrosis : one positive major criteria or >/= 4 minor criteria with at least 1 radiographical changes .

Causes of Osteonecrosis of Femoral head

Idiopathic form (Chandler’s disease )

Most common , ? COL 2A’ gene mutation / P – glycoprotein or alcohol metabolizing enzyme polymorphism )

Trauma – Neck of Femur Fracture , dislocation

Corticosteroid : cumulative 2 gms over 2-3 / 12 , increase in incidence – 4.6 fold with every 10 mg additional dose

Alcohol - > 400 ml / week

Drink years = weekly alcohol consumption * years

Coagulation disorders

Hyperlipidaemia

Dysbarism : doesnot occur < 17 psi

SLE and Connnective tissue disorders

Organs transplant

Liver Dysfunction

Radiation

Pregnancy –small body , large weight gain

Hyperuricaemia

Myeloproliferative disorder

HIV Infection

Various Pathogenic Mechanisms

Direct cellular toxicity

Extraosseous arterial

Extraosseous Venous

Intraosseous Extravascular

Intraosseous Intravascular

Multifactorial

Difference between 2 most common causes of Ostonecrosis

Idiopathic

Involves – Anterosuperior region

b/l in half of cases , upto 95 %

Post traumatic – total involvement with isolated joint involvement

How to confirm ?

Radiographs of Pelvis with Both hip joints

Involved Hip – AP and Lateral

Time to see in radiographs – 2/12 clear in 6 months

How to stage ?

Ficat and Arlet – 4 stages

Modified – STAGE O , Subdivision of stage II

University of Pennsylvania .

Tests for haemodynamic function

These tests for research purpose

            Intramedullary pressure at rest = 10-20 mmHg

                        Rapid saline injection leads to pressure rise by about 15 mmHg.

                        Osteonecrosis = Both rise by 3-4 times

            Venography

           

Classification based on Schimuzu

Treatment

Ficat and Arlet classification followed

Core Decompression +/- Bone grafting

            For stage I and IIa

Osteotomy :II and III

Trap door procedure /light bulb procedure

            IIb and III

Arthroplasty /Arthrodesis

            Stage III and IV

Avoid arthrodesis in majority , most cases are bilateral.

Inv.

CBC , ESR , CRP – To r/o Infection

Peripheral smear – to r/o blood dyscriasis

X-RAY – Pelvis + both hips

            Lateral of involved side

Bone Scan – early cases

MRI – to show b/l involvement

What is core decompression ? How to do it ?

Also called as Forage . Used to decompress hypertensive head by creating a hole extending till necrotic area.

Decreases pain.

Done as

            Isolated procedure

            With adjuvants like electric current , BMP , Demineralized bone matrix

            With bone grafting (vascularized or non-vascularized )

Hungerford Technique

Using Jewett Nail Starter  12 mm .

Ficat modified and made it 10 mm window with 8 mm central core by Michelle trephine .Additional two channels made by 5-6 mm trephine.

Entry point – just distal to vastus lateralis ridge in metaphysic to prevent fracture .

Post op single hip – partial weight bearing on two crutches in a 3  point gait.

Rationale of Core decompression

Femoral head hypertension relieved

Biological Changes

            Decrease intraosseous pressure

            Revascularization through channel or fibular intramedullary canal if used

            Prevents additional iscahemic changes

Mechanical Changes

            Removal of necrotic bone and revascularization occurs

            Subchondral graft supports cartilage

Various methods of grafting after core decompression

Cancellous (modified Ficat )

Cortical (Vacularized fibula , non vascularized strut )

Muscle pedicle bone graft : usually for traumatic osteonecrosis

Osteochondral bone grafting

            Trapdoor procedure – raise a chondral flap , curete out , fill with cancellous grafts and struts ,                                                          replace falp

            Above through – metaphyseal window  (Rosenwasser et al )

How to insert fibula ?

Harvest fibula around 9-10 cm .

Split into two , mallet through core with a canal preparation along wall , provides pathway for revascularization channels.

Principles for Free Vacularized Fibula

Harvest cancellous bone from ilium.

13 cm fibula with intact vascular pedicle (peroneal artery and branches )

Core – 2 mm wider than fibular girth , insert fibula and anastomose between peroneal stump and lateral femoral circumflex femoral vessels.

Stabilize fibula with k wires.

Release Vastus Lateralis to prevent  kinking and pressure on lateral circumflex femoral vessels .

Iliac Graft (Autogenous Cancellous ) inserted into necrotic region and around fibula before inserting graft.

Role of Osteotomy

Goals

1 Decrease intramedullary pressure / venous hypertension (biological)

2 Removal of lesion from weight bearing area (Biomechanical – to decrease progression , giving time to heal)

3 restoration of blood supply

Various Osteotomy  Options

Varus Osteotomy

            To load most lateral portion at least > 20 degrees of head laterally and < 160 degrees combined             necrotic angle required.

            Mc Murrays type Varus Osteotomy

            Pauwel’s Type Osteotomy

Valgus Extension Osteotomy (Pauwel’s )

            Moves necrotic portion laterally considerably increasing weight bearing surface and loads capital     drop osteophyte.

Sugioka Anterior Rotational Osteotomy

            Moves necrotic area anterior (upto 90 degrees can be done )

            At least 36 degrees lateral head and combine necrotic angle < 200 degrees required.

            Transtrochanteric based on LFCA

            Post rotational osteotomy also described.

            Inconsistent results.

Flexion Intertrochanteric Osteotomy (Schnider )

            Places healthy portion into weight bearing area

Valgus Flexion Osteotomy (Scher and Jackin ) with Autogenous bone grafting

Choice of Surgery

            Osteotomy

            Intertrochanteric Osteotomy

            Varus / Valgus Extension Osteotomy

Osteotomy better suited for Post traumatic Osteonecrosis.

How to plan Osteotomy ?

Evaluation on X-ray and MRI

Anterior Involvement

            Flexion Osteotomy

Anterosuperior Involvement

            Valgus Osteotomy

Posterior Involvement

            Extension Osteotomy

Posterosuperior Involvement

            Valgus Osteotomy

Superior with > 20 degrees head preserved – Curved varus or Mc Murray’s

>36 degrees preserved – Rotational transtrochanteric  Osteotomy

Modified Karboul

            X-ray and MRI

Central , coronal and sagittal cuts

To calculate combined necrotic angle

Gr 1- < 200 degrees

      2- 200-249 degrees

      3 – 250-299 degrees

      4 - >/= 300 degrees

Gr 1 Ideally suitable for osteotomy

Bakshi’s procedure

Muscle pedicle bone grafting –Quadratus femoris , TFL , Sartorius , Gluteus Medius with multiple drilling of necrotic fragment , Bakshi did it upto 60 years , till stage III , Internationally results not acceptable for >/== Gr IIA

Safe Surgical Dislocation  ?

Posteriorly Skin incision and Subcutaneuous dissection

Joint Entered from Anteriorly

Tuberculosis of Hip Joint

Examination Young Patient

Limitation of all movements

Deformity – F AD IR , Typical

Shortening

Why TB Hip

Protracted history with insidious onset of pain , night cries ,

Age group < 10 years old

Association with progressive limp

Relief with treatment

Constitutional symptoms

Our part of world – TB comes first for chronic inflammation

1 Subacute Septic Arthritis

2 Proximal Femoral Osteomyelitis with reactive hip involvement

 Thickening , broadening of trochanter , irregular proximal femur , sinuses , reactive effusion gives F AB ER

Osteonecrosis of femoral head leading to limping and deformities

3 Late Onset Perthes – less common , less flexion deformity , movement not limited in all directions , should not respond to ATT.

4 Mono-articular Rheumatoid

 Very common , occurs in middle aged , elderly , shouldnot respond to ATT.

5 Non union Neck of Femur Fracture

Trauma , chacteristic initial history , treatment history , telescopy sign + ,Flexion  ER Deformity

6 Central Fracture Dislocation of Hip

Trauma history

Movement perpendicular plane preserved .

            Even in TB Hip , movement flexion present due to squatting culture

7 Ankylosing Spondylitis

 Other joints also preserved

Other Differentials based on symptoms

1 Limitation of movement

Irritable hip

UMN Lesions – due to spasms

Relfex Irritation from Lymph nodes

2 Limp

DDH

Coxa Vara – Increase ER ,Adduction , , ER Deformity

Perthes Disease – movement not limited in all direction

Irritable Hip

Pain

Osteomyelities

SCFE

Early Poliomyelitis

Irritable Hip

Signs of Active TB

Rest pain

Night Cries ,

No joint swelling

Characteristic deformity of Stage III

Gauvain’s Negative

Staging of TB

1        Staging of Apparent lengthening (due to Pelvic Tilt to compensate abduction deformity )

>75 % pain free movement , no true shortening

>Synovitis /effusion –pathology

> FABER –Attitude

2        Stage of Apparent Shortening , movement restriction > 50 %

           

Early Arthritis

FADER

3        Staging of True Shortneing (Fixed Deformity )

            Movement restricted to < 25 %  , real shortening > 1 cm .

            Advanced Arthritis

            F AD ER

4        Stage of aftermath and destruction (wandering acetabulum , pathological dislocation , destruction of head , fibrous ankylsoing spondylitis )

Ongoing gross destruction

Shortening increases further

Deformities vary depending on final outcome

Why deformities differ in different stages ?

 Stage I – Effusion – leads to requirement for space and F AB ER Deformity

Stage II – F AD ER – Spasm of muscles

                                  Flexors and adductors are stronger than other groups so characteristic F AD ER.

                                 Irritation of inferomedial joint capsule by debris irritates obturator nerve casuing                                          adductor spasm and direct irritation of Iliopsoas by underlying swollen ,hyperemic                                        capsule

III – Eburnation of cartilage , generalized spasm increasing bony contact and enhancing destruction .

       F AD ER

Is Flexion , Abduction , IR/ ER deformity together possible ?

Yes

Patient treated by prolonged traction

Hips maintained in Hip Spica

Elderly debilitated patients who prefer to lie in lateral position and continue with initial posture for relief of pain , having weaker muscles .

Destruction of iliofemoral ligament (Inverted ligament , Y-Ligament of Bigellow)

Who continue weight bearing in initial deformed position

Cause of  Night pain ?

Night time splinting effect of muscles goes off.

Exposed subchondral bone with free nerve endings rub against each other

How to confirm diagnosis ?

x-RAY Pelvis AP with Both Hip joints

                        Involved hip –AP , Lateral with whole femur

CBC,ESR,

Skin tests

Immunosorbent Assays – ELISA : IgG , Ig M response to A60 Ag .

Fluid Analysis –PCR

                        Increased Protein , Poor formation of mucin clot

                        Staining (Zeihl-Neelson )

                        Culture –very slow

                        Rapid alternatives

                                                BACTEC TB 460 ,MGI T 960

Rapid Methods

            Centrifused samples

            Thin layer and gas liquid interphase chromatography for detection of lipids and long chain fatty       acids

            Radiosensitive DNA labeled probes specific to diagnose genus species and subspecies

            MDR rapid diagnosis :

                        Genotypic analysis rpo B 531 , rpo B 526 , rrs 513 ,rps L 43

                        Molecular hybridization techniques

Note

Staining requires 10,000 /mm³  bacilli

Culture requires 1000/mm³ bacilli .

X-ray Changes –

Involvement of femur and acetabulum

Decreased joint space

Cystic Sclerosis on head /acetabulum

Upriding Greater Trochanter

F AD ER

Joint Subluxation and displacement of fat planes

Classification of TB-Clinico-radiologically

Normal Hip

Travelling acetabulum

Dislocating Hip

Perthe’s Disease

Mortar and Pestle Type

Atrohpic

Protusio Acetabulum

Adult –atrophic form , children –normal ,pethes and dislocating

Both –mortar and pestle ,wandering and protusio types.

Radiological signs of TB

Osteoporosis

Cat bite lesions –articular margin

Decreased joint space

Destructive changes

Early stage – osteoporosis , later – Osteosclerosis

Pathological signs of Healing

Increased thickness of trabeculae

Increased density of bone

Recommencing of epiphyseal growth

Pathology of Untreated Hip

1 Synovial type

            Hypertrophic granulation tissue leading to cartlage destruction ,

            Bridging bony surfaces

            Leading to fibrous Ankylosis

2 Bony Extension type

            Via subperiosteal space or direct metaphyseal spread , after breeeching cartilage leading to Deformity and shortening

Clinical types of hip joint TB

            Granular form : common in adults , less destruction , decreased tendency for cold abscess

            Casseous type : severe constitutional symtomps , common in childhood

            Trabecular Rheumatism (Pancet’s disease ) : Asymmetric polyarthritis + focus of infection

What are rice bodies ?

Accumulation of ? rice and fibrin

Focus of infection in TB

Synovium

Bone –acetabulum

            Femur – Babcok’s triangle ,watershed area between obturator and femoral circulation ,weaker in                              this region.

                        Lies – in cervical side of lower part of head  ,

                                    proximal part of neck in lower half  near epiphyseal line

            Head of femur

            Trochanteric region

Aim of treatment

Obtain a painless , mobile ,stable hip ,

Methods of treatment

Heliotherapy

            Liberal diet

            Fresh air

            Restrain from exertion until healing

           

Chemotherapy

           

Traction – to correct deformity and maintain deformity with intermittent mobilization.

Surgery

Role of Chemotherapy

WHO regime

Intensive phase – 3/12

            HFRZE ,At least one bactericidal

            Evaluate culture report

Extension phase – 4.12

            HRZ

Continuation phase

            HR

Intensive phase kills rapidly multiplying bacteria .

Continuation phase kills

                                    dormant bacteria

                                    Prevents recurrence

How much traction do you give ?

0.45 kg /year of traction

Give B/L traction as unilateral may increase abduction

Relative tilt also increases

Slight abduction is also asvisable.

            Compensates real shortening

            Abduction is seen in convalescence

Role of surgery in TB Hip

Obtain tissue diagnosis

Formal debridement in clinically non responsive TB

Manage deformity

            Hip Arthrodesis  for painless, stable ,immobile joint

            Modified girdlestone arthroplasty – gives unstable painless mobile joint.

Total hip replacement – painless , stable and mobile joint.

Indications for surgery

Clinically non responsive TB

Failure to obtain acceptable outcome (unacceptable deformity ) after completion of conservative treatment

Painful healed disease due to secondary outcome

What do you mean by excision of focus ?

Removal of disease tissue-synovium , bone

Curettage

Limb immobilized in acceptable position follow

Surgery done in proper ATT cover – 6 weeks to 2 months pre surgery.

Complications of Surgery

Fulminant progression

Osteonecrosis of femoral head

Pathological fracture femoral neck

Slippage of capital femoral epiphysis

Chondrolysis

Pathological dislocation of hip

What do you expect ?

In stage III – Painful healed disease with ATT.

What do you do ?

Explain patient the functional limitations . Know functional demands.

What do you do then ?

Hip arthrodesis for painful hips.

Indications of hip arthrodesis

Young active patient doing hard work and putting lot of stress on joint.

Failure to arrest disease after 1 year of supervised treatment.

Relapse and recurrence of pain and deformity

Drestructive disease (sequestrum in head of femur /acetabulum )

In general , a young adult with no life limiting or activity limiting unilateral hip disease and not a candidate for osteotomy / ? arthroplasty

Types of hip Arthrodesis

Intra-articular

Central dislocation

            Internal compression arthrodesis of Charnley

Watson-Jones transarticular nail arthrodesis

Intramedullary arthrodesis of Onji

Cobra Plate arthrodesis

Extra-articular

Iliofemoral arthrodesis of Albee

Ischiofemoral Arthrodesis of Brittain

Para-articular – done to augment I/A Procedure

Davis –muscle pedicle arthrodesis

Which do you prefer ?

Intra-articular arthrosis using cobra plate

I have seen this

Joint debridement can be done simultaneously

Large raw surfaces can be carved out to enhance chances of union

More secured fixation

No alteration of anatomy

Destroyed joint space can be filled with bone graft with a good approximation in intra-articular methods.

Role of extr-articular arthrodesis ?

Done in premises that opening diseased joints flar up of infection.

It was done before with no availability of good chemotherapy.

They destroy anatomy of joint making future procedures difficult.

Position of fixation

Flexion 30 degrees

1 degree / year above 10 years , till maximum 30 degreeabove 25

Compensated by lumbar lordosis for ground clearance.

Abduction /Adduction – neutral or 5 degree adduction

Abduction leads to later development of frontal plane knee deformity.

Rotation – 0 to 15 degree ER .

Brittain’s method of extra-articular arthrodesis

Subtrochanteric osteotomy , incise ischium , grafted with a massive tibial graft into defect

Alternative – McMurray’s osteotomy

Arthrodesis contraindications

Ongoing uncontrolled active infection

Opposite hip , ipsilateral knee already arthrodesed
severe  degenerative changes in lumbar spine , opposite hip and ipsilateral knee

When to do THR ?

Classically after 10 years

Ambitiously after 1 year , under ATT cover

                        After 6 weeks from experience of spine

Girdle stone Arthroplasty

Debridement of septic joint , surrounding soft tissue with free drainage creating a type of excisional arthroplasty.

First described by ? Gathome Gridlestone

Modified Girdlestone

Taylor ,Nelson , Nagi

Current concept – retain adequate amount of bone and no acetabulum surgery or extensive muscle debridement using posterior approach.

Management of post operative approach following Girdlestone Resection

Tuli and Mukharjee – 6-8 weeks skeletal traction in Thomas splint with pearson attachement to prevent ER  in 30 – 50 degrees attachement with radiographic demonstration of distraction at operative site and ?

Mobilization of hip and knee aftee  1 week

6-8 weeks skin traction

Walking in  caliper – 1 year

What can be done to treat instability after girdlestone resection ?

PSO of Milch AND Batchelor type .

What is Milch Batchelor type Osteotomy ?

Resection angulation osteotomy  described as two stage procedure.

Stage 1 ) release of pelvis and restoration of femoral mobility resecting femoral head and neck

Stage 2 ) restablishment of stability by means of PSO

(Schanz ) . Two stages combined one by Milch and Gruca (New York ) as traction after stage 1 and immobilization after stage 2 ,wasted a lot of time .

Essence of osteotomy is post osteotomy angle that should place proximal femoral congruent to lateral pelvic wall (mean lateral pelvic wall tilt :205-210 degrees ) else the aim would be defeated.

Ilofemoral approach , sacrifices neve to TFL .Angulation osteotomy  done at level of ischial tuberosity

Distal fragment should be abducted (lengthens to compensate true shortening ) and internally rotated else spontaneous ER would again destabilize pelvic support.

Other types of PSO

Schanz , Ganz, Lorenz (Bifurcation Osteotomy ),Mc Murray’s

Role of PSO

Surgically shifts shaft of femur  near centre of gravity so axis of weight bearing is more along axis of femur .

Supports pelvis by creating medial fulcrum

Improves adduction function by creating valgus

Abduction of distal fragment leads to gain in length .

Phemister Triad

Described in TB Hip .consists of

Juxta articular osteoporosis

Peripherally located osseous lesion

Gradual narrowing of joint space

Triangles in relation to hip

Babcok’s triangle

Ward’s triangle

            Between tensile , primary compressive trabecuale and calcar portion of neck ,relevant in      osteoporosis and fixation of hip fracture.

Fairbank’s triangle

            Seen in coxa vara

Bryant’s triangle

Femroal (Scarpa’s triangle )

Abductor triangle

            Between gluteus medius , ilium and Neck of Femur (Displays abductor mechanism)

Role of manipulation under anaesthesia

Indicated in healing diseases with less severe deformities to

Attempt gaining mobility of hip while on treatment when articular cartilage is supposedly preserved

Provide a functional position (correcting deformity ) to hip lest it goes on fibrous ankylosis when cartilage reepairably damaged and functions can’t be regained.