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Osteonecrosis

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  • Bed rest, crutches and non-steroidal analgesics
    • Retrospective studies and meta-analyses have proven these to be ineffective at slowing disease progression, particularly in lower-limb joints
    • Some studies suggest that conservative management of shoulder osteonecrosis consisting of limited overhead use, gentle stretches and strengthening exercises and analgesics may be as successful as surgical therapies
  • Bisphosphonates : shown to delay disease progression and joint replacement
  • Newer pharmacologic options
    • Still largely unproven for treatment of osteonecrosis
    • Potential promising therapies include
      • Growth factors
      • Cytokines
      • Angiogenic agents
      • Bone morphogenetic proteins

...

  • Joint preserving procedures
    • These procedures attempt to preserve the femoral head and slow disease progression
    • Core decompression
      • Provides pain relief
      • Increases range of motion in early stage disease
    • Vascularized fibular graft
      • Provides structural support, stem cells and a vascular supply to the necrotic tissueShown to be much more successful at delaying or preventing the need for joint replacement
      • Results with this technique have been highly variable {ref: 12690862}. Complications include donor site morbidity (~24% rate){ref:  9692940} and proximal femur fracture (~2.5% rate) 20 . Conversion to total hip arthroplasty in patients who have undergone this procedure requires burring laterally to prevent the prosthesis from being placed in varus.
    • Bone marrow grafting
      • Currently experimental
      • Favorable early reports
    • Osteotomy
      • Creates a new weight bearing area away from the necrotic area
      • Has varying clinical results with the best results seen in early stage disease.
  • Joint replacement
    • Used for end-stage osteonecrosis when the joint is destroyedOptionssevere degenerative changes are present
    • Options
  • Even surgical therapies do not restore joints back to normal and patients still have some degree of pain
  • Core decompression
    • Relieves pain and increases range of motion best in early stage disease
    • When implemented in early stage disease, it may decrease the number of patients needing eventual total joint replacement
  • Cortical grafts
    • Low success rate of
      • Hemiarthroplasty
        • Hemiarthroplasty has poor long-term results. The high activity level in this patient population results in increased polyethylene wear and osteolysis. This technique should not be used in these patients.

      • Hemi-resurfacing arthroplasty of the femoral head
        • Indicated when there is no acetabular involvement
        • This procedure initially had high failure rates, but has improved with the development of more advanced implant technology
      • Total joint replacement
        • Has worse results than replacement for other conditions
        • It has overall acceptable long-term results
        • Patients often need revisions

Outcome

Conservative Management
  • Current treatments are largely palliative
  • For the most part they do not delay disease progression
Surgical Treatment
      •  
        • Disadvantages include unpredictable relief of groin pain, which is a complaint in up to 20% of these patients. Also, this is a temporizing measure as failure will eventually occur secondary to acetabular cartilage erosion. Short-mid term results have been relatively encouraging with 5-7 year success rates are approximately 70-90%. At 10-15 years there has been a dramatic decrease in survivorship.
      • Total joint replacement
        • For hip disease, short to mid-term results with newer bearing surfaces and uncemented techniques have been encouraging. Success rates of up to 89% have been reported at 15 years follow-up making THA a reliable, long term option.

Outcome

Conservative Management
  • Bisphoshonates;
    • A prospective, randomized, controlled trial has reported the results of 54 patients with large pre-collapse or early post-collapse lesions randomized either into a group that received observation only or a group treated medically with alendronate for 25 weeks. Seven percent (2/29) of the lesions treated with alendronate had progressed at a minimum 2-year follow-up versus 76% (19/25) of the controls 14 .
Surgical Treatment
  • Core decompression 
    • For hip disease a success rate of 84% for Stage I lesions and 65% for Stage II lesions has been reported {ref:  8595753}. 
    • Efficacy of the procedure drops significantly once the femoral head develops a subchondral fracture.

  • Cortical grafts
    • Success rate as low as 25%
    • Combined with core decompression, it has better outcome in intermediate early stages of the disease
  • Vascularized fibular grafting
    • Highest Highly variable results across the literature. A few institutions specializing in this technique have reported acceptable success rates
    • >80% improvement in symptom and pain relief
    • .
  • Total hip replacement
  • 5 year failure rate in patient's younger than 40 years old is 15-20%, esp. in patients who are overweight or physically active
  • Prosthetic hips are unlikely to last the entire lifetime of patients
  • Patients with osteonecrosis have poorer clinical outcomes with regard to such symptoms as pain reduction and range of motion than patients with osteoarthritis, although patients with idiopathic or traumatic osteonecrosis have better outcomes than patients with steroid-induced osteonecrosis
  • A retrospective review compared total hip replacement in patients with osteonecrosis vs. replacement of hips in patients with osteoarthritis
    • Revision rate was higher in patients with osteonecrosis (28% vs. 6%)
    • The time of revision was on average 5 years earlier in osteonecrosis patients
  • Poor prognostic factors
    • Older than 50 years of age
    • Advanced disease at the time of diagnosis
    • Necrosis of more than one third of the weight-bearing area of the femoral head on MRI
    • Lateral involvement of the femoral head
    • Short to mid-term results with newer bearing surfaces and uncemented techniques have been encouraging. Success rates of up to 89% have been reported at 15 years follow-up making THA a reliable, long term option.

Complications

  • The main complication of conservative management is disease progression to subchondral bone collapse and joint destruction
  • Complications of joint conserving treatments are serious
  • Any surgical intervention carries the usual risks of anesthesia, infection, and suboptimal results
  • The most common complication of core decompression, reported in 0-18% of cases, is hip fracture
  • Vascularized fibular grafting
    • It is a more complicated procedure than other bone grafts, so it has related morbidity consequences; all of which must be considered especially in older patients
    • Disadvantages
      • Longer recovery
      • Less complete analgesia
      • Variable success rate
      • Decreased effectiveness in advanced osteonecrosis
    • Complications
      • Ankle pain
      • Great-toe flexion contracture
      • Foot motor weakness and sensory loss
      • Femoral fracture
      • Deep vein thrombosis
      • Pin migration
      • Hematoma
      • Trochanteric bursitis
    • The overall complication rate for vascularized fibular grafting was found to be 17% at an average of 8 years
    • 4% of total cases required additional surgery or chronic pain management
  • Total hip replacement
    • Deep vein thrombosis (103-20%5%)
    • Dislocation (21-5%)
    • Osteolysis Infection (1-10%2%)
    • Infection (<1:2500 to <1:5000)
    • Neurovascular injury (<1:1,000)

References

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