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Avascular Necrosis

The document discusses avascular necrosis, specifically pertaining to Perthes disease. Perthes disease, also known as Legg-Calve-Perthes disease, is aseptic avascular necrosis of the capital femoral epiphysis that most commonly affects children between the ages of 4-8 years old. It is caused by interruption of the blood supply to the femoral head, which can lead to bone death. Treatment aims to contain the femoral head within the acetabulum through methods such as bracing or surgery, with the goal of allowing the femoral head to reform in a concentric manner and prevent deformity or degenerative joint disease.

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Rohit Nath
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86 views44 pages

Avascular Necrosis

The document discusses avascular necrosis, specifically pertaining to Perthes disease. Perthes disease, also known as Legg-Calve-Perthes disease, is aseptic avascular necrosis of the capital femoral epiphysis that most commonly affects children between the ages of 4-8 years old. It is caused by interruption of the blood supply to the femoral head, which can lead to bone death. Treatment aims to contain the femoral head within the acetabulum through methods such as bracing or surgery, with the goal of allowing the femoral head to reform in a concentric manner and prevent deformity or degenerative joint disease.

Uploaded by

Rohit Nath
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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AVASCULAR NECROSIS

WHAT IS A.V.N ?

 Necrosis of bone due to lack


of
blood supply of bone.
LACK OF BLOOD SUPPLY
Due to Septic cause

SEQUESTRATION

Due to Aseptic cause

ASEPTIC AVASCULAR NECROSIS


ETIOLOGY
ASEPTIC AVASCULAR NECROSIS

TRAUMATIC

NON TRAUMATIC
Idiopathic - commonest
Prolonged corticosteroids administration
Chronic Alcohol abuse
Coagulation disorders etc.
ETIOPATHOGENESIS
DIRECT
Severance of local blood supply
Constriction
Thrombosis

INDIRECT- compression of capillaries & sinusoids.


Increased Intracapsular pressure
Tamponade effect
COMMON SITES OF A.V.N.

Femoral head
Proximal pole of scaphoid
Body of talus
Capitulum
Head of humerus
Femoral condyles .
EPIPHYSIS

EPIPHYSITIS

OSTEOCHONDRITIS

OSTEO CHONDROSIS
EPIPHYSEAL SITES OF A.V.N.
FEMORAL HEAD - PERTHES DISEASE
TIBIAL TUBEROSITY - OSGOOD SCHLATTER’
DISEASE
CALCANEAL - SEVERE’S DISEASE
CAPITULUM - PANNER’S DISEASE
LUNATE - KIENBOCK’S DISEASE
VERTEBRAL RING - SCHEURMANN’S DISEASE
NAVICULAR - KOHLER’S DISEASE
PERTHES DISEASE
ASEPTIC AVASCULAR NECROSIS OF CAPITAL
FEMORAL EPIPHYSIS

Also known as
 Coxa plana ,
Coxa magna
Pseudocoxalgia,
Legg-calve-perthes disease,
Osteochondrosis of femoral head
BLOOD SUPPLY
OF
HEAD OF FEMUR
LAT. EPIPHYSEAL
A.
BLOOD SUPPLY OF HEAD OF
FEMUR
ADULTS
UPTO 3-4 YEARS
FROM 3-4 Yrs TO 8-10 Yrs
BLOOD SUPPLY CONTD.
Children – upto the age of 4 yrs- metaphyseal vessels
mainly.

Between 4-8 yr-femoral head depends for its blood


supply & venous drainage almost entirely on the lateral
epiphyseal vessels

After 9-10 years like adults


EPIDEMIOLOGY
Most common age group : 4 to 8 yrs
Incidence among sex - M:F = 4:1
Incidence of bilateralness : 10-12%
Positive family history : 10%
Higher association in abnormal birth presentation –
breech or transverse lie
Etiology
Unknown
Interruption of blood supply
disturbed venous drainage
intraosseous venous hypertension
increased viscosity
capsular tamponade
thrombophilia, hypofibrinolysis
Post inflammatory,
post traumatic
PATHOGENESIS
Lateral epiphyseal vessel
- Stretching in extreme
abduction or extetrnal rotation

Kinking, leading to decreased


blood flow

Venous stasis

Rise in intraosseus pressure

Ischaemia

Death of femoral ossific


nucleus.
STAGING
Stage I : Stage of synovitis

Stage II : Ischaemia & bone death

Stage III: Revascularization & repair

Stage IV: Reparative stage


CATTERALL CLASSIFICATION
GROUP-1
anterior half of nucleus is sclerotic,
epiphyseal height maintained

AP VIEW LATERAL
VIEW
GROUP- 2
upto half of nucleus is sclerotic,
epiphysis has some collapse

AP VIEW
LATERAL VIEW
GROUP- 3
most of the nucleus is involved,
fragmented & collapsed.

LATERAL VIEW
AP VIEW
GROUP- 4
whole head is involved , ossific nucleus is flat ,

dense with metaphyseal resorption.

AP VIEW LATERAL VIEW


CLINICLAL FEATURES

SYMPTOMS

Pain in groin and Anterior thigh pain


Insidious onset of limp
Muscle wasting
ON EXAMINATION
Gait – From Antalgic to Trendlenberg gait
ASIS at a higher level due to adduction
deformity
Shortening
Restriction of movements especially abduction
and internal rotation
Muscle wasting
X-RAY FINDINGS
Smaller size of ossific nucleus
Widening of medial joint space
Increased density of ossific nucleus
Fragmentation
Crescentric sub articular fracture
Flattening & lateral displacement of epiphysis
Rarefaction/ cystic changes in metaphysis
Widening of metaphysis
Diagnosis
Radiology
AP and frog-leg pelvis radiographs

X-Ray series showing the changes in Perthes Disease


Differential diagnosis
Transient synovitis
Tuberculosis
Congenital coxa vara
Hip dysplasia
Sickle cell disease
Pyogenic infection
J. R.A.
Gouchers disease
PROGNOSTIC FACTORS
AGE-most important prognostic factors
< 6yrs – excellent
>6yrs –poor
SEX- girls have poorer prognosis
Stage
Grading(various classification)
Treatment prescribed & their complaince
TREATMENT
Primary aim of the treatment
is the containment of femoral
head in the acetabulum – this
help femoral head to reform
in concentric manner
(biological plasticity) & first
principle in the treatment is
restoration of motion
Primary goals of treatment are-

 Restoration of motion
 Prevention of deformity
 Prevention of growth disturbances
 Prevention of degenerative joint
disease
TREATMENT
MODALITIES
Rest and traction to the affected limb
in abduction, slight flexion and medial
rotation applied for 3wks
Reassess the patient, to determine
further management-
Containment method
Non-containment method
Containment Method
By holding the hips widely
abducted, in plaster or
removable brace
By surgery
Varusosteotomy of the femur
Innominate osteotomy of the pelvis
Varus Osteotomy
Valgus osteotomy
Valgus Osteotomy to reduce hinge abduction
Cheilectomy
Innominate osteotomy

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