Avascular Necrosis of the Hip-1

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Kristin Landeros, Lizzie Philbin, Allison Vaupel

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Avascular Necrosis of the Hip:

Avascular Necrosis of the Hip February 21, 2013 Kristin Landeros Lizzie Philbin Allison Vaupel

Avascular Necrosis (AVN)1:

Avascular Necrosis (AVN) 1 Also called osteonecrosis, ischemic bone necrosis, and aseptic necrosis Osteonecrosis is bone death caused by poor blood supply to the area Most common in the hip and shoulder

Causes2:

Causes 2 Vascular (e.g. sickle cell disease) Infection (septic emboli) Drugs/toxins (steroid use, alcohol) Inflammatory (pancreatitis) Congenital ( Gaucher’s disease) Autoimmune (rheumatoid arthritis) Trauma (fracture) Endocrine/metabolic (Cushing’s disease)

Stages of Avascular Necrosis2:

Stages of Avascular Necrosis 2 Stage Radiologic Staging of AVN of the Femoral Head 0 Normal radiograph film, normal bone scan, and MRI I Normal radiograph film, abnormal bone scan or MRI II Sclerosis and/or cyst formation in femoral head III Subchondral collapse (crescent sign) without flattening IV Flattening of head without joint narrowing or acetabular involvement V Flattening of the head with joint narrowing and/or acetabular involvement VI Advanced degenerative changes

Signs and Symptoms1,2:

Signs and Symptoms 1,2 No symptoms in early stages Late stage symptoms include Pain in joint that may increase over time, and will become very severe if the bone collapses Pain that occurs even at rest Limited range of motion Groin pain Limping

Prognosis:

Prognosis AVN can have a widely differing prognosis 3 Healing can depend on the cause, stage of disease at diagnosis, amount of involved bone, age and overall health 4 Better prognosis with small affected area 5 Severe AVN can lead to subchondral fracture, degenerative joint disease and joint dissolution 5

Treatment5:

Treatment 5 Early stage Limit use of affected area D ecrease weight bearing of affected limb ROM exercises within pain free range Pain reliever medication Late stage Surgery Bone graft with or without blood supply Osteotomy Total joint replacement Decompression to allow for increased blood flow

Methods of Diagnosis:

Methods of Diagnosis CT MRI Radiograph Bone scan

Imaging:

Imaging http://radiographics.rsna.org/content/27/4/1005/F16.large.jpg http://www.imagingpathways.health.wa.gov.au/includes/DIPMenu/avas_nec/image.html

Imaging:

Imaging Radiographic Description: A B C S

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A B C S

PowerPoint Presentation:

A B C S

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A B C S

T1 Coronal MRI Findings:

T1 Coronal MRI Findings Flattening of right femoral head Peripheral band of low signal in superior portion of femoral head outline bilaterally, right > left, representing bone edema Diffuse low signal within femoral head bilaterally, right > left, representing bone edema Decreased joint space bilaterally

Biomechanical & Physical Impairments6,7:

Biomechanical & Physical Impairments 6,7 Patients will present to PT with gait and ADL dysfunctions Some dysfunctions include: Antalgic gait and/or Trendelenburg gait Stiffness and decreased ROM of hip joint Decreased muscle bulk on affected side Pain with movement, long periods of walking and weight bearing May u tilize assistive device, such as cane or walker ADL dysfunction (decrease ability to): Don/doff socks, shoes, pants, etc. Ascend/descend stairs with reciprocal pattern Sit to stand without upper extremity support Walking fast/running Increased sitting time Getting in/out of car

Questions:

Questions What is the “crescent sign” and when would you expect it to appear on diagnostic imaging? What physical therapy interventions would be appropriate in the early and late/post-surgical stages of AVN?

References:

References McKinnis LN. Radiologic evaluation of the pelvis and hip. In: Fundamentals of Musculoskeletal Imaging , 3rd Ed. Philadelphia, PA. FA Davis; 2010: 355-359. 2. Langdon L. Imaging Notepack : Unit 4 Sacroiliac Joint, Pelvis, and Hip . University of St. Augustine, 2013. University of Washington. Osteonecrosis . UW Medicine Department on Radiology. http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/osteonecrosis. Accessed February 20, 2013. Board ADAME. Osteonecrosis . 2011. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004519/. Accessed February 20, 2013. Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage. Indian J Orthop . 2009;43(1):6–16. doi:10.4103/0019-5413.45318. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders : Physical Therapy Principles and Methods. 3 rd Ed . Philadelphia, PA:Lippincott -Raven; 1996: 298-303. Journal of continuing medical education in radiology. Website. http://radiographics.rsna.org/content/27/4/1005.full. Accessed February 16, 2013.

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