1. What is Avascular Necrosis or Osteonecrosis?
2. What are the symptoms of Avascular Necrosis?
3. What are the causes of Avascular Necrosis?
4. What are the risk factors for developing Avascular Necrosis?
5. What are the investigations needed for diagnosis?
6. What are the stages of Avascular Necrosis?
7. What are the treatment options for Avascular Necrosis?
8. What complications can occur in untreated Avascular Necrosis?
9. What is Core Decompression?
10. What is Core Decompression with BMAC insertion?
11. What are the different types of hip replacements?
12. What are the different bearing options in Total Hip Replacement?
A lack of blood supply to the tissue within the bone leads to its death called Avascular necrosis or Osteonecrosis. It can sometimes lead to tiny breaks within the structure of the bone and eventually its collapse. The hip is the most commonly affected area with osteonecrosis. Other than the hip, commonly affected areas are the knee, shoulder, hand and foot.
The early stages of avascular necrosis may not be associated with any symptoms. However, the affected joint may begin to hurt as the condition progresses and the person puts on weight in the affected area. The primary symptom of avascular necrosis is pain which develops gradually and can be mild or severe. Sometimes the pain may persist even on lying down. The pain is located at the centre of the groin or radiates to the area of the thigh or buttock. In certain persons, (4 to 5 out of 10) avascular necrosis may be bilateral, i.e., it develops on both hip joints.
Osteonecrosis usually affects people between the ages of 25 and 50. The primary cause of avascular necrosis is the interruption of blood supply within the bone which can be caused by:
Many factors can increase the likelihood of avascular necrosis such as:
Some of the medical conditions that increase an individual’s susceptibility to avascular necrosis include:
The diagnosis of avascular necrosis is performed by an Orthopaedic Surgeon based on medical history, physical examination and tests. Tenderness and movements may be assessed by pressing around the joints and moving them during physical examination.
Imaging tests: Advised to determine the source of pain
There are usually four stages of avascular necrosis.
Stage I: Progress from a normal, healthy hip to pain observed in the groin area
Stage II: Pain and stiffness
Stage III: Pain radiates to the surrounding areas like the knee
Stage IV: Pain and limp on the affected side
The goal of treatment in avascular necrosis is to manage the symptoms and prevent further bone loss. Sometimes, the condition may be self-limiting and can be managed conservatively. The treatment is a combination of conservative and surgical management when required.
Surgical options: Since the symptoms of osteonecrosis develop mostly when the condition has progressed far, the orthopaedic surgeon might recommend surgery. The commonly done surgical procedures include:
Avascular necrosis is progressive in nature. If left untreated, it deteriorates with time and eventually, the bone may collapse. Progressive avascular necrosis also leads to loss of the smooth surfaces of the thereby causing severe arthritis.
In this procedure, the affected part of the femoral head is drilled to relieve pain and pressure in the bone. This could provide pain relief and prevent rapid progression to arthritis in select patients when there is no subchondral fracture/ collapse of the head.
In this procedure, the affected bone is drilled and bone marrow aspiration from Iliac crest (pelvic bone) is taken and centrifuged in a machine. This concentrate is injected into the drilled hole in the bone to help in new bone formation to strengthen the affected bone.
The different types of hip replacements available include:
The different bearing options in Total Hip Replacement include:
The Metal-on-Polyethylene has been the gold standard for a long duration. However, long term (>20 years) results of Ceramic bearings appear to be promising. Ceramic-on-Ceramic and Ceramic-on-Polyethylene has demonstrated to be functioning well at 20 years of follow-up studies.
References:
About Author –
Dr. Praveen Mereddy, Consultant joint Replacement & Trauma Surgeon, Yashoda Hospitals – Hyderabad
MS (Ortho), DNB (Ortho), MRCS (Ed), M.Ch (Ortho), FRCS (Ortho)
Complex Primary Hip and Knee Replacement Surgery, Partial Knee Replacement Surgery, Treatment of Painful/Unstable/Failed (Loosening/infection) Primary Joint Replacements, Complex, complicated fractures and Pelvi-acetabular trauma
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