AVASCULAR NECROSIS- Courtney Maggio, Stephanie Serafin, Kristin Tripp

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Courtney Maggio, Stephanie serafin, Kristin tripp June 8, 2012 AVASCULAR NECROSis

Description of avn:

Description of avn Avascular necrosis (AVN) is a disease resulting from the temporary or permanent loss of blood supply to the bones. 1 Without blood, the bone tissue dies and ultimately the bone may collapse. 1 AVN commonly affects the epiphysis of the femur and can also include the knee, shoulder, ankle, and rarely the jaw. 1 There are four stages as classified by FICAT classification system for AVN. 1

Ficat classification system for AVN:

Ficat classification system for AVN Stage 1 The conventional radiograph is normal; however, the MRI findings will confirm AVN. 2 Stage 2 Cystic and sclerotic changes are observed on conventional radiographs, MRI imaging. 2 Stage 3 A crescent sign is observed on conventional radiographs and MRI’s. 2 Stage 4 Flattening of the femoral head, narrowing of the hip joint, and ultimately severe joint destruction is observed on the conventional radiograph as well as MRI. 2

Signs & symptoms of AVN:

Signs & symptoms of AVN Many people have no symptoms in the early stages of AVN. 3 Pain associated with AVN of the hip may be focused in the groin, thigh, knee, or buttock. 4 As the disease worsens, there will be pain upon weight-bearing that is relieved by rest. 3 PROM is limited and painful, especially in internal rotation and abduction. 3 Resisted straight leg raise will be painful. 4 The pain can be mild or severe and usually develops gradually. 1 Eventually the pain will be constant. 4


incidence According to the American Academy of Orthopaedic Surgeons , 10,000-20,000 people develop AVN each year. 1 A number of predisposing conditions are associated with the development of AVN. Causes of AVN are described by the mnemonic VINDICATE by Richardson: 3,5 V ascular (e.g. sickle cell disease) I nfection (septic emboli) D rugs/toxin (steroid use, alcohol) I nflammatory (pancreatitis) C ongenital ( Gaucher’s disease) A utoimmune (rheumatoid arthritis) T rauma (fracture) E ndocrine/metabolic (Cushing’s disease) Notes and richardson


diagnosis Diagnosis of AVN is primarily completed with imaging tests and patient history. 4 Use of traditional radiographs can detect the disease; however, MRI can detect early changes in the bone that may indicate AVN as early as two weeks of vascular compromise. 4


prognosis Prognosis of AVN depends on: 6 Cause of ANV (VINDICATE) S tage of disease upon diagnosis A mount of bone involvement Age O verall health

Impact of functioning:

Impact of functioning Patient will experience pain upon weight-bearing of the affected leg. 3,7 Patient may present with range of motion limitations, compensations at the spine, possible leg length discrepancy, as well as gait deviations. 7

Role of imaging in the diagnosis & management of AVN:

Role of imaging in the diagnosis & management of AVN Once AVN is established, any imaging method will indicate the presence AVN. 3 In the early stages of AVN, MRI is of great value as it is usually diagnostic. 9 Plain radiographs are unremarkable in stage 0 and stage 1. 9 In stage 2 of AVN, MRI is invaluable as it is virtually always diagnostic. 9 For detecting necrosis as well as the stages of AVN, MRI has proven to be the best imaging method. 8

T1 MRI of AVN:

T1 MRI of AVN http://radiopaedia.org/cases/previous-avascular-necrosis-of-the-left-hip?fullscreen=true

Description of t1 mri of avn:

Description of t1 mri of avn This T1 weighted MRI image is showing degeneration and necrosis of the left femoral head. The image details sclerosis of the left femoral head with flattening. The dark region or low signal intensity is denoting the border between the dead tissue and the living bone, or the necrotic region. The left femoral head also demonstrates bone marrow edema, as indicated by the brighter fluid seen within the femoral head and neck. The image demonstrates a large osteophyte on the superior lateral ridge of the femoral head. The image is showing joint space destruction with acetabular rim involvement of the left hip and possible soft tissue edema.

Plain radiograph image of AVN:

Plain radiograph image of AVN http://gait.aidi.udel.edu/educate/clcsimge/sickle5.jpg

ABC’s for AVN radiograph:

ABC’s for AVN radiograph Alignment: The femoral head is no longer rounded and is misshaped with a noticeable contour in the superior and lateral aspect of the head Femoral head flattening with subchondral collapse No exotoses noted Undefined region of the fovea capitus Possible observed coxa valga but unable to measure due to inadequate size of image Bone Density: Sclerosis of the acetabular rim and the femoral head Density decreased in the superior/lateral aspect of the femoral head Osteolytic activity in the femoral head Indistinct cortices of the femoral shaft Cartilage Space: Narrowing of the joint in the medial and caudal aspect Increased joint space in the superior and lateral aspect secondary to necrosis and residual deformity of the femoral head Soft Tissue: From the limitations of a standard radiograph, we hypothesis possible soft tissue swelling around the necrotic tissue, but further imaging such as an MRI would be best to definitively confirm soft tissue swelling. Other surrounding soft tissues demonstrate normal contour.

Impairments hypothesized from ti mri and plain radiograph:

Impairments hypothesized from ti mri and plain radiograph Based on the above images, the patient may have the possible following impairments: Range of motion limitations, especially internal rotation and abduction Pain with weight-bearing Gait deviations Based on the TI MRI, we hypothesize that the AVN stage is a stage four evidenced by the flattening of the femoral head and extent of necrotic damage. Based on the plain radiograph, we estimate that the AVN stage is also a stage four secondary to femoral head flattening and the appearance of a crescent sign. Our hypotheses were made based on the FICAT classification system for AVN.


questions Based on the TI MRI image, what physical therapy interventions, if any, would be beneficial for this patient? What is a possible referral for the patient based upon the TI MRI image?


references Osteonecrosis (Avascular Necrosis). National Institute of Arthritis and Musculoskeletal. 2011. Available at: http://www.niams.nih.gov/health_info/osteonecrosis/ . Accessed on June 8, 2012. Pappas J. The musculoskeletal crescent sign . Radiology . 2000; 217: 213-214. Conrad E. Imaging For Physical and Occupation Therapists. St. Augustine, Florida: The University of St Augustine for Health Sciences; 2012. Avascular Necrosis. Mayo Foundation for Medical Education and Research. 2012. Available at: http://mayoclinic.com/health/avascular-necrosis/ds00650/dsection=symptoms . Accessed on June 8, 2012. Richardson. Osteonecrosis. Department of Radiology University of Washington. 2008. Available at: http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/osteonecrosis . Accessed on June 8, 2012. Osteonecrosis. PubMed Health. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004519/ . Accessed on June 8, 2012. Patla C, Chaconas E, Conrad E, at al. Musculoskeletal I: Orthopaedics. St. Augustine, Florida: The University of St Augustine for Health Sciences; 2011. Benis J , Turpin F . The role of imaging in the assessment of vascularity at hand and wrist. Chir Main. 2010;29(12):21-27 . Fang C, Teh J. Imaging of the hip . Imaging . 2003; 15: 205-216.

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