AVN Diagnosis & Treatment
AVN Hip joint Diagnosis

Diagnosis And Treatment

Diagnosis of AVN needs a comprehensive approach involving clinical inputs and radiological findings.

Clinical findings:

A doctor examines the patient thoroughly and checks for tenderness in joints. He might move joints through a variety of positions to check patient’s range of motion. In addition to the physical examination, understanding patient’s age along with detailed history is equally important. Occurrence of serious diseases in the past or previous medications may provide some diagnostic clues.

Imaging/ Radiology

Obtaining an image of bone is crucial for the diagnosis of AVN. Usually, a patient is asked to undergo a simple X-ray image of the joint.

Magnetic Resonance Imaging (MRI) is recommended for early-stage disease onset. It is the most sensitive and specific method of Diagnosing AVN. It has the ability to detect the disease as early as 5 days after initiation of necrosis!

Radiological findings are essential to determine the Stage of disease and quantity of bone death.

AVN Xrays

Stages of Osteonecrosis

The stage of the disease gives an idea about the progress of the disease. It simply means how much of the bone area is dead. Various systems are being used for disease staging however, a system formulated by the Association Research Circulation Osseous (ARCO) is widely used in clinical practice.

AVN Chart
AVN Diagnosis Chart

How treatment works?

Disease Management (Temporary Measures)

Bone Cell Therapy:
 
It is a newer treatment modality wherein bone cells called Osteoblasts are introduced in the dead bone to prevent bone collapse after core decompression. The reports published in the peer renewed international journal – cited encouraging with more than 70% of patients not requiring hip replacement surgery at even 8 years.
 
With the dawn of the new century and the last decade of the previous century, new research emerged that avascular necrosis (AVN) is not to the lack of blood supply. Recent research has shown that people who developed avascular necrosis have got a poor regeneration capacity. Hauzer was the first surgeon to introduce bone marrow into the blood into the femoral head. The results of this process were better than core decompression and done as a stand-alone process in the year 2006. Hauzer published his reports of a process called BMAC (bone marrow aspiration centrifuge). This involved minimal treatment of the bone marrow where the bone marrow was centrifuged and certain cells in the centrifuge are then introduced into the femoral head his results were encouraging and showed that there was a significant improvement in patients of AVN and they were able to delay the hip replacement.
3 Generation Of Orthobiologics
Bone Cell Therapy
Bisphosphonates:
 
They inhibit the action of osteoclasts, which play a function in bone degradation. In this way, bisphosphonates inhibit the process of bone degradation. As the degradation is hampered probability of bone collapse is reduced. They also stimulate the proliferation of pro-osteoblast cells which synthesize bone cells. They help in the reduction of swelling at the site of AVN.
Core decompression (CD):
 

Core decompression is the process by which a hole is made into the femoral head by a surgical procedure it was believed that drilling a hole into the femoral head will lower the pressure into the femoral head and allow restoration of blood supply. However, this has not stood the test of time in 1960 Ficat and Arlet who are French doctors and they noticed a certain pattern of X-rays of patients having hip pain as they were no MRI or CT scan at that time commonest method of diagnosis was a biopsy.

A small drill to the femoral head to remove this bone for biopsy they noticed that these patients became relatively pain-free and so was born core decompression and they identified a new disease called as an AVN in 1970 Dr. David s Hungerford worked with this French doctors and he introduced this disease and it’s treatment into America and the English-speaking world he labeled it as core decompression.

Core decompression remained popular till the year 2000 as there was not much research going into the cause and treatment of avascular necrosis.

The current role of core decompression as a standalone procedure is not recommended nowadays because it has got a very high chance of failure. However, core decompression is used along with another treatment like bone marrow or BMAC as a way of introducing auto biological substances into the femur head to get a better result than core decompression alone.

 

Core Decompression With or Without Bone Marrow Aspirate Concentrate

 

Core Decompression:

1. Identify the Dead Bone

Core Decompression

2. Remove Dead Bone

3. Inject Ossgrow

Bone grafting:
 
Generally done through the core decompression tract, the process involves filling the drilled area with either living bone tissue (obtained from other areas) or non-vascularized tissue. The former helps in the ingrowth of vascular cellular tissue in the region of dead bone whereas the later provides structural stability to the hip.
Total hip replacement:
 
It is the end-stage treatment required in case of joint collapse. In the last stage of AVN when a bone is completely dead, the individual is in deep pain and unable to move joint. In such cases, total hip replacement is the only option. In this treatment, the damaged bone and cartilage is removed and replaced with artificial metal joint. The shelf life of the metal prosthesis and recent infection news is recent causes of concern Treatment is decided considering the age of the patient and stage of the disease. It is generally recommended after other options fail and age is over 60 years.
It should be remembered that AVN is a progressive disease. Early diagnosis is better for better treatment outcome.

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