Osteonecrosis of the Hip
Osteonecrosis of the hip is a painful condition that occurs when the blood supply to the head of the femur (thighbone) is disrupted. Because bone cells need a steady supply of blood to stay healthy, osteonecrosis can ultimately lead to destruction of the hip joint and severe arthritis.
Osteonecrosis is also called avascular necrosis (AVN) or aseptic necrosis. Although it can occur in any bone, osteonecrosis most often affects the hip. More than 20,000 people each year enter hospitals for treatment of osteonecrosis of the hip. In many cases, both hips are affected by the disease.
After discussing your symptoms and medical history, your doctor will examine your hip to discover which specific motions cause your pain.
Patients with osteonecrosis often have severe pain in the hip joint but relatively good range of motion. This is because only the femoral head is involved in the earlier stages of the disease. Later, as the surface of the femoral head collapses, the entire joint becomes arthritic. Loss of motion and stiffness can then develop.
Osteonecrosis is typically seen as a wedge-shaped area with a dense whitish sclerotic border in the superior lateral portion of the femoral head. On lateral view, a lucent line called a “crescent sign” can often be seen just below the surface of the femoral head.
Magnetic resonance imaging (MRI) scans.Early changes in the bone that may not show up on an x-ray can be detected with an MRI scan. These scans are used to evaluate how much of the bone is affected by the disease. An MRI may also show early osteonecrosis that has yet to cause symptoms (for example — osteonecrosis that may be developing in the opposite hip joint).
Stages of Avascular Necrosis-Osteonecrosis Hip
photo credit AAOS American Academy of Orthopaedic Surgeons
Video Link of Stages of Avascular Necrosis-Osteonecrosis Hip
Dr Nabil Ebraheim Shows Info on Hip Avascular Necrosis
You can have Avascular Necrosis in one hip or both , if in both hips it’s called bilateral which means both sides.
And if you have Avascular Necrosis- osteonecrosis in more that 3 different joints
Multifocal osteonecrosis is defined as disease involving three or more anatomic sites.
That is called multi focal Avascular Necrosis- Osteonecrosis
Multifocal osteonecrosis Article in The Journal of Rheumatology 25(10):1968-74 · November 1998
Multifocal ON, which ON involves three or more distinct anatomical sites , is rare, being seen in only approximately 3% of all ON patients . Corticosteroid use is a known risk factor for multifocal ON [5,6], as are certain comorbidities, including systemic lupus erythematosus (SLE), renal failure, leukemia, and lymphoma [5,7,8]. However, almost all studies of multifocal ON are case reports and case series, so the inci- dence and clinical characteristics of the condition remain poorly defined [5,. …
There is no known pharmaceutical cure for osteonecrosis. Several non-operative treatments have been studied including hyperbaric oxygen therapy, shock wave therapy, electrical stimulation, pharmaceuticals (anticoagulants, bisphosphonates, vasodilators, lipid lowering agents), physiotherapy and muscle strengthening exercises, and combinations thereof. There are conflicting results for some of these treatments, therefore, rigorous, randomized controlled trials with large numbers of patients are still needed to determine the effectiveness of these treatments. Non-operative treatment may be part of a wait-and-see approach based on the size of the area of dead bone. Non-operative treatments cannot be labeled as conservative, since many of them do not slow the progression of the disease or lead to avoidance of a total hip arthroplasty. Most are simply pain-relieving at best.
Reduced weight bearing does not alter the course of the disease and is not a treatment. It may be used to simply permit the patient to better cope with pain until appropriate treatment is instituted.
Core decompression – This surgical procedure removes or drills a tunnel into the area of the affected bone, which reduces pressure within the bone. Core decompression works best in people who are in the earliest stages of osteonecrosis, before the collapse of the dead bone. This procedure sometimes can reduce pain and slow the progression of bone and joint destruction in these patients.
Osteotomy – This surgical procedure reshapes the bone to reduce stress on the affected area. There is a lengthy recovery period, and the patient’s activities are very limited for 3 to 12 months after an osteotomy. This procedure is most effective for patients with advanced osteonecrosis and those with a small area of affected bone.
Bone graft – Bone grafts can be used as part of the surgical treatment for osteonecrosis. Bone grafts can use bone from the same patient or donor bone. Bone graft or synthetic bone graft can be inserted into the hole created by the core decompression procedure. A specialized procedure, called vascularized bone grafting, involves moving a piece of bone from another site (often the fibula, one of the bones of the calf, or the iliac crest, a portion of the pelvic bone) with a vascular attachment. This allows for support of the diseased area as well as a new source of blood supply. This is a complex procedure and is performed by surgeons that are specially trained. Another type of bone grafting, involves scraping out all of the dead bone and replacing it with healthier bone graft, often from other portions of the patient’s skeleton.
A unique type of bone graft involves the use of a patient’s own cells that are capable of making new bone. Often these cells are a type of stem cell from the bone marrow or other bodily tissues. There has been increasing interest in the potential of stem cell therapy. This is also being studied for the treatment of osteonecrosis. Mesenchymal stem cells, which are a type of ‘adult’ stem cell, can grow and develop into many different cell types in the body. Physicians take the patient’s own mesenchymal stem cells (autologous transplant) and place them into the affected bone to stimulate bone repair and regeneration.
Arthroplasty/total joint replacement – Total joint replacement is the treatment of choice in late-stage osteonecrosis when the joint is destroyed. In this surgery, the diseased joint is replaced with artificial parts. It may be recommended for people who are not good candidates for other treatments, such as patients who do not do well with repeated attempts to preserve the joint. Various types of replacements are available, and people should discuss specific needs with their doctor.
For most people with osteonecrosis, treatment is an ongoing process. Doctors may first recommend the least complex and invasive procedure, such as protecting the joint by limiting high impact activities, and watch the effect on the patient’s condition.
Other treatments then may be used to prevent further bone destruction and reduce pain such as core decompression with bone graft/stem cell therapy. Eventually patients may need joint replacement if the disease has progressed to collapse of the bone. It is important that patients carefully follow instructions about activity limitations and work closely with their doctor to ensure that appropriate treatments are used.
Scientists, researchers, and physicians continue to pursue a better understanding of how this disease occurs as well as compare the effectiveness of current and newly developed therapies. Often, this requires a clinical trial to answer questions and gain additional knowledge.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Toll-free: (800) 411-1222
TTY: (866) 411-1010
Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update.
By Dr. Michal Mont MD
There is hope
The goal is to prevent further bone loss.
Medications and therapy
In the early stages of avascular necrosis, symptoms might be eased with medication and therapy. Your doctor might recommend:
- Nonsteroidal anti-inflammatory drugs.Medications, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve) might help relieve the pain associated with avascular necrosis.
- Osteoporosis drugs. Medications, such as alendronate (Fosamax, Binosto), might slow the progression of avascular necrosis, but the evidence is mixed.
- Cholesterol-lowering drugs. Reducing the amount of cholesterol and fat in your blood might help prevent the vessel blockages that can cause avascular necrosis.
- Blood thinners. If you have a clotting disorder, blood thinners, such as warfarin (Coumadin, Jantoven), might be recommended to prevent clots in the vessels feeding your bones.
- Rest. Reducing the weight and stress on your affected bone can slow the damage. You might need to restrict your physical activity or use crutches to keep weight off your joint for several months.
- Exercises. A physical therapist can teach you exercises to help maintain or improve the range of motion in your joint.
- Electrical stimulation. Electrical currents might encourage your body to grow new bone to replace the damaged bone. Electrical stimulation can be used during surgery and applied directly to the damaged area. Or it can be administered through electrodes attached to your skin.
Surgical and other procedures
Because most people don’t develop symptoms until avascular necrosis is fairly advanced, your doctor might recommend surgery. The options include:
- Core decompression. The surgeon removes part of the inner layer of your bone. Besides reducing your pain, the extra space within your bone stimulates the production of healthy bone tissue and new blood vessels.
- Bone transplant (graft). This procedure can help strengthen the area of bone affected by avascular necrosis. The graft is a section of healthy bone taken from another part of your body.
- Bone reshaping (osteotomy). A wedge of bone is removed above or below a weight-bearing joint, to help shift your weight off the damaged bone. Bone reshaping might enable you to postpone joint replacement.
- Joint replacement. If your diseased bone has collapsed or other treatments aren’t helping, you might need surgery to replace the damaged parts of your joint with plastic or metal parts.
- Regenerative medicine treatment. Bone marrow aspirate and concentration is a newer procedure that might be appropriate for early stage avascular necrosis of the hip. Stem cells are harvested from your bone marrow. During surgery, a core of dead hipbone is removed and stem cells inserted in its place, potentially allowing for growth of new bone. More study is needed.
Talk to your doctor about treatment options and the stage of your Avascular Necrosis of the Hip.
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Wishing you a pain free day