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Osteonecrosis of the Hip | AVN

Treatment

  • Eliminate any cause if possible

Stage 0/1/2

  • Nonoperative Options
    • observation or protected weight bearing
    • Electrical stimulation alone- remains experimental- not approved by FDA
    • Pharmacological no controlled studies - agents include Hydergine, naftidrofuryl, vincamine, nifedipine, stanozol
  • Operative options
    • Forage/ core decompression -
      • ref: Fairbank etal JBJS77A: 681-694, 1995
        • 89 pts, 104 hips average FU 7yrs, uses Marcus classification
        • stage 2: 2/19 (10%) progression to THR
        • stage 3: (crescent sign only, no collapse) 5/22 (23%)
        • stage 4: (collapse, no Osteoarthritis) 17/40 (43%)
        • stage 5: (Osteoarthritis) 7/22 (32%)
      • ref Yoo etal CORR 1992 81 hips ( 59 stage 2, 22 stage 3)
        • av age 36 yr, average FU 5yr treated with vascularised fibular graft
        • stage 2: 8% progression
        • stage 3: 19% progression
    • Other
        • Vascularised quadratus femoris graft (Meters)
    • Conclusion
        • forage precollapse lesions
        • ?vascularised fibular grafting for large stage 2 lesions

Stage 3/4

  • Osteotomy
    • Sugioka
      • high failure rate
      • conventional- similar high failure rate especially with large necrotic fragment, steroid or alcohol related cases
      • May be indicated in the patient without steroid associated disease & a smaller necrotic fragment ( combined necrotic angle less than 200 deg)
      • NB may compromise later THR
    • arthrodesis
      • in young patient with unilateral disease e.g. trauma
      • problem is that 50-80% of cases are bilateral
      • THR
      • consider if patient more than 40 years
      • note higher failure rate in THR for AVN - due to younger patients & ↑ demands
        • Conclusion: best to manage conservatively until bad enough to perform THR