Insights Into Avascular Necrosis of the Femoral Head : Learning for the Trainees and Professionals

The book is an overview of a vital Orthopedics topic, avascular necrosis (AVN) of the hip. It encompasses all the aspects of this disease in terms of etiology, epidemiology, pathogenesis, diagnosis, staging, and treatment. It covers the recent advances and evidence-based approaches to diagnosis and management, with easy to understand tables and pictures. This book is a comprehensive guide with chapters on presentation and examination of such a case with knowledge about frequently asked questions. Included multiple-choice questions on the topic will further aid in revision and recapitulation. This book is a helpful tool for Senior Residents, faculty members in teaching institutions as well as practicing Orthopedic surgeons all across the globe. Knowing how to examine, diagnose and manage a case of AVN hip is a must for any Orthopedic surgeon, and they have to be aware of all recent advances without fail. This book is on a topic which is a “must keep” clinical case in all Orthopedic exit exams; encapsulated with every nuance of the disease, it will be beneficial across all the career stages of Orthopedic surgeons. Foreword 6 Preface 8 Contents 10 Editors and Contributors 12 About the Editors 12 Contributors 13 1: Femoral Head: Anatomical Considerations 14 1.1 Introduction 14 1.2 Articular Surface (Fig. 1.2) 16 1.3 Structure of the Head of the Femur (Fig. 1.3) 17 1.4 Femoral Offset (Fig. 1.4) 18 1.5 Ligament of the Head of the Femur (Ligamentum Capitis Femoris) (Fig. 1.2) 18 1.6 Femoral Neck 19 1.7 Surface Landmark 19 1.8 Relations (Fig. 1.5a–c) 20 1.9 Vascular Supply (Fig. 1.6) 22 1.10 Nerve Supply 22 1.11 Development (Fig. 1.7) 23 1.12 Conclusion 23 References 23 2: Avascular Necrosis of the Hip: Historical Perspective 25 2.1 Introduction 25 2.2 Pathogenesis 26 2.3 Evolution of Classification Systems 27 2.4 Treatment 28 2.5 Preservation of the Femoral Head 28 2.5.1 Core Decompression 28 2.5.2 Grafting 30 2.6 Joint Reconstruction 30 2.7 Conclusion 31 References 31 3: Epidemiology and Risk Factors 34 3.1 Introduction 34 3.2 Epidemiology 34 3.3 Risk Factors for AVN Hip 36 3.3.1 Non-modifiable Risk Factors 36 3.3.1.1 Age 36 3.3.1.2 Genetic Predisposition 36 3.3.1.3 Race 37 3.3.2 Modifiable Risk Factors 37 3.3.2.1 Substance Abuse 37 3.3.2.2 Drug Intake 38 3.3.2.3 Autoimmune Disease 39 3.3.2.4 Trauma 39 3.3.2.5 Metabolic Disorders 39 3.3.2.6 Irradiation 40 3.3.2.7 Dysbaric Diseases 40 3.3.2.8 Hematological 40 3.4 Conclusion 40 References 40 4: Etiology and Pathophysiology of AVN 43 4.1 Introduction 43 4.2 Etiology of Avascular Necrosis 44 4.3 Blood Supply of the Femoral Head 44 4.4 Pathoanatomy of Traumatic AVN 45 4.5 Pathoanatomy of Nontraumatic AVN 46 4.5.1 Intravascular Changes 46 4.5.2 Extravascular Changes 46 4.6 Genetic Associations of AVN 48 4.7 Pathophysiology of AVN 48 4.7.1 Pathological Changes in Bone 48 4.7.2 Pathological Changes in Articular Cartilage 51 4.7.3 Pathological Changes in Synovium 51 4.8 Quantification of the Necrotic Segment 51 4.9 Conclusion 52 References 53 5: Clinical Features and Staging of AVN Hip 54 5.1 Introduction 54 5.2 Clinical Features 55 5.3 Classification Systems for AVN Hip 56 5.4 Ficat and Arlet Classification System [2, 10] 56 5.5 Association Research Circulation Osseous (ARCO) [3, 13] 61 5.6 Steinberg Classification (University of Pennsylvania Classification) [4, 14] 62 5.7 The Japanese Investigation Committee Classification [15] 63 5.8 Conclusion 64 References 64 6: Avascular Necrosis Hip: How to Examine a Suspected Case 66 6.1 History 66 6.2 Past Medical, Family, and Personal History 67 6.3 General Examination 68 6.4 Gait 68 6.5 Local Examination 68 6.6 Summary 83 References 83 7: AVN Hip: Radiology 84 7.1 Introduction 84 7.2 Pathophysiology 84 7.3 Radiological Features 85 7.3.1 Radiographs 85 7.3.2 CT 85 7.3.3 MRI 87 7.3.4 Nuclear Imaging 91 7.4 Predicting Subchondral Collapse 91 7.5 Radiological Differential Diagnosis 93 7.6 Summary 93 References 93 8: Treatment Principles: An Overview 95 8.1 Background 95 8.2 Pre-collapse Stages 96 8.2.1 Biophysical Treatments 97 8.3 Post-collapse 102 8.4 Conclusion 103 References 105 9: Core Decompression 107 9.1 Introduction 107 9.2 Indications 108 9.3 Contraindications 108 9.4 Conventional Technique (Hungerford) 109 9.4.1 Position 109 9.4.2 Incision 109 9.4.3 Exposure 109 9.4.4 Entry Point and Reaming 109 9.4.5 Precautions 112 9.5 Common Errors 112 9.6 Modifications of Technique 112 9.7 Augmentation of CD 112 9.8 Outcomes 113 9.9 Postoperative Rehabilitation 114 9.10 Conclusion 114 References 114 10: Osteotomies for Osteonecrosis Hip 117 10.1 Introduction 117 10.2 Indications 117 10.3 Preoperative Work-Up 119 10.4 Positioning and Anesthesia 119 10.5 Osteotomies 119 10.6 Conclusion 124 References 125 11: Head Preservation: Recent Advances 127 11.1 Introduction 127 11.2 Diagnosis and Assessment 127 11.3 Treatment Strategies 128 11.4 Recent Advances in Hip Preservation 128 11.4.1 Adjuncts Used Along CD 129 11.5 Conclusion 132 References 132 12: Hip Arthrodesis: Current Concepts 134 12.1 Background 134 12.2 Indications 135 12.3 Contraindications 135 12.4 Optimal Position 135 12.5 Surgical Technique 135 12.6 Problems and Outcome 138 12.7 Current Status 139 12.8 Summary 139 References 139 13: Hip Arthroplasty 141 13.1 Background 141 13.2 Excision Arthroplasty 141 13.3 Bipolar Hemiarthroplasty 142 13.4 Hip Resurfacing Arthroplasty 142 13.5 Total Hip Arthroplasty 143 13.6 Implant Options 145 13.6.1 Cemented Femoral Stem 145 13.6.2 Cementless Femoral Stem 147 13.6.3 Cemented Acetabular Components 147 13.6.4 Cementless Acetabular Components 148 13.6.5 Hybrid THA 149 13.6.6 Reverse Hybrid THA 149 13.7 Bearing Options 150 13.7.1 Ultrahigh Molecular Weight Polyethylene 150 13.7.2 Metal-on-Metal Articulations (MoM) 150 13.7.3 Ceramic-on-Ceramic Articulations 151 13.8 Literature 153 13.9 Conclusion 154 References 154 14: Avascular Necrosis of the Hip: Replace or Resurface? 156 14.1 Introduction 156 14.2 History of Hip Resurfacing 157 14.3 Patient Selection for Hip Resurfacing 158 14.4 Indications 159 14.5 Contraindications 159 14.6 Hip Resurfacing Versus Total Hip Arthroplasty 159 14.7 Conclusion 162 References 162 15: AVN Hip: Bedside Case Presentation 164 15.1 History 164 15.1.1 General Points to Be Remembered for History [1] 164 15.1.2 Demographics 165 15.1.3 Chief Complaints 165 15.1.4 Past History 167 15.1.5 Personal History 167 15.1.6 Family History 167 15.1.7 Summary After History 168 15.2 Examination [2–4] 168 15.2.1 General Points to Be Remembered for Examination 168 15.2.2 General Physical Examination [1] 168 15.2.3 Systemic Examination 168 15.2.4 Local Examination 169 15.2.4.1 Gait 169 15.2.4.2 Inspection 169 15.2.4.3 Palpation 170 15.2.4.4 Deformity and Movements 170 15.2.4.5 Measurements 170 15.2.4.6 Special Tests [4, 5] 171 15.2.4.7 Miscellaneous Tests 172 15.2.5 Summary After Examination 172 15.2.5.1 Radiological Investigations [3] 172 15.3 Conclusion 173 References 173 16: Frequently Asked Viva Questions (AVN Hip) 174 16.1 Introduction 174 References 186 17: Multiple-Choice Questions 188 References 199