Avascular necrosis is the most common cause of hip pain in the young and middle aged population. The most common reason is idiopathic or unknown. Other causes include steroid intake, blood disorders, fractures of the neck of femur, alcoholism.
The disease is very common in the age group 20 to 50.
Treatment options are
1) Non surgical- This has a poor rate of cure.
2) Surgical- Surgical treatments can be further divided into joint replacement or non joint replacement. Non joint replacement measures are core decompression and regenerative therapy with bone forming stem cells. This modality of treatment is relatively new and is available in India at a modest cost.
Joint Replacement- This consists of hip resurfacing, BHR, Birmingham mid head resection (BMHR),Short stem hip replacements, Birmingham mid head resection and total hip replacement with an uncemented or cementless prosthesis.
The bearings used need to be long lasting and devoid of side effects. Metal on metal bearings are used in Hip resurfacing and BMHR.
Ceramic on ceramic or ceramic on metal or ceramic on poly bearings can be used with short stem and total hip replacements. Ceramic on ceramic bearings result in the least amount of wear. Metal bearings can produce some amount of wear particles.
Most procedures mentioned above are bone preserving operations with the exception of a total hip replacement.
We have been performing short stem hip replacements with the Proxima hip since the last 5 years.
Young AVN patient
A few years ago, it was the common perception that joint problems were a problem of old age and young were spared. This is far from the truth today and in years to come. Orthopedic surgeons are seeing increasing numbers of young patients with end stage arthritis proceeding to Joint replacement.
Take the case of thirty eight year old Radhika from Bangalore. Both her knees are worn out from osteoarthritis. Osteoarthritis usually affects older people but young patients with certain risk factors, injury or a genetic pre disposition can get it much earlier. She is going to require knee replacements soon. Another example is Safia from Mangalore who at the age of forty five has already had bilateral Oxinium knee replacements done. Her main contributory risk factor was obesity. The photo is a young African patient who underwent hip resurfacing three years ago. His video testimonial is provided here. http://www.youtube.com/watch?v=-k9F9NpF8UI
It is contextual to deliver this message today on the occasion of World Arthritis day says Dr.Venkatachalam an orthopedic surgeon from Chennai, India. Arthritis refers to any affection of a joint leading to swelling, pain, noise, and restriction of movements. World arthritis day is commemorated each year on October 12th to raise awareness of joint problems. This year’s theme is “Let us work together”.
Conditions leading to end stage arthritis in the young are rheumatoid arthritis, post traumatic arthritis, ankylosing spondylitis, post infective arthritis, hemophilic arthritis and osteoarthritis in the genetically prone young patient. The end result is a breakdown of articular cartilage, the natural shock absorber.
Increasing incidence of joint problems amongst the young has led to a commiserate increase in demand for intervention as the young are not content with resting at home or taking medicines. This population of so called “baby boomers” wants to enjoy life to the hilt & be able to earn their living.
Early diagnostic radiologic methods like MRI can pick up disease in its earlier phase. Laboratory diagnosis of ‘Rheumatoid arthritis a debilitating disease is also possible with blood tests.
Early diagnosis enables surgeons to offer newer methods of treatment and perhaps even nip the disease in its bud. Disease modifying drugs, stem cell therapy, advances in joint replacement are examples of advances.
Cartilage surgery is a method of biological treatment. Damaged articular cartilage is repaired or regenerated. Autologous chondrocyte implantation an established technique has been introduced in India in its latest technological advance. This fourth generation cartilage regeneration technique is invaluable for treating lesions in high demand patients like athletes.
Joint replacements also have got a boost in the last two years. Earlier Joint replacement had a survivorship of ten to fifteen years. A young patient in need of a Joint replacement was certain to need a revision surgery later on. This requirement is now mitigated with the availability of implants made of durable materials like Oxinium. Oxinium is a metal substrate with a ceramic coating. Oxinium knees & hip implants offer longevity, low friction and non allergenicity.
Madras Joint Replacement center is dedicated to restoring mobility & flexibility.
Avascular necrosis of the hip 
is a frequently seen condition in young patients. It is of diverse origin and its treatment is controversial. Surgical treatment remains the key stone in late cases with hip replacement as the proved and tested method. Surgeons at the Madras Joint replacement center are proud to announce a novel form of biological treatment with stem cells. It can be performed for patients with the early stages of the disease.
When the disease is detected early by MRI scans, it is possible in India now to perform a biological treatment.
In fact a biological treatment option of early disease is a medical necessity and must be the treatment of choice whenever possible.
A novel approach to this condition is being mooted by a leading Orthopedic surgeon in Chennai, India. This is by means of stem cells. Stem cells have the potential to regenerate any tissue. In this case, bone forming stem cells are utilized to synthesize new bone over the dead bone. Stem cells are harvested from the pelvis of the patient.
There are two techniques being promoted. One is a three stage procedure and the other is a single stage procedure. Both procedures are done in India, implying that you will save thousands of dollars in treatment costs.
The first method is by stem cell culture in the lab to multiply the number of cells several million fold. These cultured stem cells are reinjected into a previous core decompression site.
In the second method, bone marrow obtained from the pelvis is centrifuged in the operating room to yield a Bone marrow concentrate rich in stem cells. These are injected into a core decompression site.
A paper presented at the recent American academy of surgeons meet in New Orleans highlighted the success story of stem cells.
http://www.prweb.com/releases/adultstemcellAVNsurgery/thomaseinhornmd/prweb3813974.htm
To know more about the stem cell option and to determine whether your case is suitable for this unique form of treatment, send an e mail to
Dr.A.K.Venkatachalam at drvenkat@kneeindia.com
Visit http://www.hipsurgery.in/blog
To get more information please e mail us
drvenkat@kneeindia.com
Web site- http://www.hipsurgery.in
Dr.A.K.Venkatachalam gave two talks at the Arab health summit in Dubai. The topics were regenerative medicine in Orthopedics. He talked about Ossron therapy for Osteonecrosis. With the declining popularity of Hip resurfacing for Osteonecrosis or avascular necrosis, the biological options look appealing in the early stages. For a successful outcome, aggressive investigations with MRI scan and bone scan is essential. Patients will benefit only if they seek early treatment rather than procrastinate.
Sickle cell patients often suffer from avascular necrosis or osteonecrosis. Hip replacement is required for pain relief. They are also prone to develop bone infections due to their lowered immunity. While investigating a patient, the orthopedic surgeon should consider the possibility of a co existent infection in the hip and take steps to eradicate it. Joint replacement in the presence of an ongoing infection is likely to be disastrous.
Osteomyelitis & Avascular necrosis in sickle cell patients
Avascular necrosis of bone is a common problem in patients with sickle cell disease.
Hip is the commonest joint driving patients to seek hip replacement.
However this scenario can be complicated by osteomyelitis (bone infection)
In this case report, we discuss how this combination was approached.
Case report
The patient was a 34 year old Nigerian male, one out of 6 siblings. All other siblings were normal. Both parents were haploid for sickle cell trait.
He presented with severe avascular necrosis of the left hip needing a hip replacement.
Work up included a complete blood count, ESR, Haemoglobin electrophoresis, blood culture, pre operative X-rays of the hip. The ESR was elevated at 121 mm/ hr and his WBC count was 12,000/cu mm. Blood culture was negative.
The x ray of the pelvis revealed avascular changes of both hips with secondary osteo- arthritic changes. The proximal portion of the left femur showed a bone in bone appearance with some discontinuity seen in the region below the greater trochanter.
An MRI with contrast was done. This showed a breach in the cortex with a bright signal intensity which was negative to fat suppression. There was edema in the surrounding tissues and an effusion was present in the hip joint. A CT guided biopsy was taken from the area and this drew a sample of yellowish fluid. This fluid was set up for culture in two labs. One lab reported a negative culture and another lab reported a growth of scanty “coagulase negative staphylococcus.”
With a near positive diagnosis of chronic osteomyelitis, the patient was taken up for an open debridement.
The hip was approached by a lateral approach with division of the vastus lateralis.
A cavitary lesion was identified below the greater trochanter.
It was debrided thoroughly and specimen sent for culture.
Bio absorbable bone substitute of Calcium sulphate and antibiotic was packed inside the cavity to deliver a high local concentration of antibiotics, Vancomycin and Tobramycin.
In addition intra venous infusion of Vancomycin and Clindamycin was started.
The patient is making progress. 
Discussion
This case helps to draw attention to the co existence of infection in sickle cell patients with avascular necrosis. Performance of a hip replacement without eradication of infection would have lead to disastrous results.
This cautious approach can possibly eradicate infection and allow a safe hip replacement later on.
Another aspect is the method of local antibiotic delivery. It is well known that intravenous antibiotics have poor tissue concentration in the affected bone. The prevalent method of local antibiotic delivery is combination of antibiotics with Bone cement (Poly methyl methacrylate). This comes in the form of Septopal beads which contain Gentamycin. This is impregnated into the affected area after an open operation; however this restricts the choice of antibiotics. It requires another operation to remove the beads after 6 weeks.
The main advantage of our technique is that the procedure achieves two purposes. Firstly it allows packing of the bony defect with a bone substitute. This substitute is resorbed over 60 days and osteogenesis occurs. Secondly antibiotics are delivered in high concentration locally for duration of three months. There is no need for a second operation to remove the beads as it is self absorbing.
Dr.A.K.Venkatachalam
MS Orth, DNB Orth, FRCS. M.Ch Orth
Consultant orthopedic surgeon
Madras Joint Replacement center
Stem cell treatment of avascular necrosis.
A novel form of treatment is now available in India for patients with early stage avascular necrosis of the hip. This treatment is based on regenerative medicine.
Avascular necrosis of the hip is a condition of unknown origin affecting many young and middle aged patients. Steroid intake, alcoholism, Sickle cell diseas, hypertension, decompression sickness are some known causes. Moderate to severe disease is treated by hip resurfacing whereas core decompression is offered to the first stage of the disease. Grade II A disease is an intermediary stage between the two extremes and has no definite treatment options. There is controversy on the appropriate treatment. Hip replacement is perhaps too drastic an operation for this early stage of the disease. Core decompression has limited success rate. Left to progress it leads to deterioration and hip arthritis.
For this stage, a biolgoical option is now available. This is based on the potential of stem cells to heal the avascular bone. Stem cells are drawn from the patient and cultured in the lab. A few weeks later, they are injected back into the affected portion of the femoral head along with a core decompression. In a core decompression the surgeon will drill a tunnel in the hip bone leading into the affected area. The regenerative bone cells are injected into the affected area. The bone forming cells called Osteoblasts synthesize new bone in the dead area. This leads to healing and hence a biological cure. The technique is called Ossron
This process is avaiable in India for a reasonable cost.
To get a quote please e mail us at drvenkat@kneeindia.com
Hip arthritis is of two types. Young and middle aged persons suffer from secondary osteoarthritis. Primary osteoarthritis can affect middle aged and elderly. Surgery in this group of relatively younger patients requires newer techniques like hip resurfacing.
Hip Resurfacing is the preferred option in young & middle aged males with primary
Types of Hip arthritis
Hip arthritis is classified as Primary and secondary Osteoarthritis.
Primary osteoarthritis is age related wear and tear arthritis. It is rare in India.
Secondary osteoarthritis occurs at a younger age and is more common. Rheumatoid arthritis, avascular necrosis, traumatic arthritis and other connective tissue disorders like SLE, Psoriasis etc. all lead to secondary osteoarthritis.
Rheumatoid arthritis is an auto immune disorder, affects all joints particularly the small joints but also does not spare the hip and knees.
Avascular necrosis is a condition that reduces the blood supply to the end of the bone. It affects patients with excess alcohol intake, consuming steroids, connective tissue disorders like SLE. Systemic lupus erythematosus (SLE) is a connective tissue disorder affecting mainly young women A photo sensitive rash on the cheeks, renal involvement and arthritis are some notable features. Avascular necrosis affects a proportion of the patients with SLE.
Gaucher’s disease is a rare genetic storage disorder.
Post traumatic arthritis occurs after a severe injury to the hip. Fractures of the ball (top of the femur) or socket (acetabulum) can lead to arthritis after inadequate treatment.
Hip arthritis is very disabling as it is a small ball and socket joint. In advanced disease a total hip replacement was recommended by Orthopaedic surgeons until recently. The ideal age for a hip replacement is 74 years.
Surgical solutions
are the mainstay of treatment as conservative measures fail to relieve pain. Total Hip replacement (THR) is a time tested operation and has a success rate of 93 % survivor ship at 10 years.
Who needs a hip resurfacing?
In India, many young patients with ankylosing spondylitis, avascular necrosis, post septic arthritis, post injury suffer from hip arthritis and are advised a hip replacement for disabling pain. Thus many hip replacement operations are performed in younger patients. The surgery should cater to the enhanced demands on an artificial joint by younger and more active patients. Naturally an operation designed for Western elderly patients is not suitable for younger patients.
Hip Resurfacing vs Hip Replacement
In this operation the ball shaped upper end of the thigh bone (femur) and the socket (acetabulum) are replaced. The ball is replaced with a long metal stem that is fixed into the upper end if the thigh bone. Its upper spherical end articulates with a cup shaped polyethylene socket that is cemented into the pelvis.
Conventional hip replacements sacrifice a great deal of normal bone as the head, neck, and upper part of the thigh bone is removed for implantation of the prosthesis. Moreover wear debris from the poly-etheylene liner lead to osteolysis and bone loss. When this first hip is to be changed or revised after its lifespan more bone loss occurs. Conventional hips have a small ball to reduce friction and wear, but the ill effect of this is an increased risk of dislocation. An average dislocation rate of 3- 4 % has been reported. These implants do not last very longer than 20 years and revision rates of 50% at 20 years have been reported. Survival rates are less satisfactory for the relatively younger active patients. Thus a total hip replacement is not an ideal implant for younger patients less than fifty years old who need a new hip.
Problems with conventional total hip replacement:
- Excessive bone sacrifice and loss
- Increased risk of dislocation
- Patients cannot squat or sit cross legged on the floor with out the risk of dislocation.
- Range of movement is less
- Patients cannot involve in sports
- Poor survival in young and active patients they require earlier revision.
- Revision surgery is difficult
- The hip feels less like a normal hip
- The cup wears with time and plastic from it harms bone
- Change in length of the leg after surgery leading to leg length discrepancy.
Why remove normal bone when only the surface of the ball is bad?
This is the logic behind hip resurfacings. This bone preserving hip resurfacing involves replacing only the diseased bony surfaces of the head of femur and acetabulum. This involves sculpting the head of the femur and covering it with a metal cap and fixing an uncemented socket into the acetabulum to receive the head.
Hip Resurfacing- A bone preserving hip replacement!
Preservation of bone and less stress shielding makes it easy to revise this hip if needed. The large head size provides a very stable joint and recreates the sensation of a normal hip joint. Patients have gone back to playing Judo and Squash after this operation. Advances metallurgy makes the metal on metal articulation likely to survive longer in the young and active patient. With less metal inside the bone and less invasion of the medullary cavity of the femur, the risk of infection is reduced. Rehabilitation is faster and better.
Advantages of hip resurfacing:
- Allows the patient to squat and sit cross legged on the floor safely
- Allows a normal range of movement
- Sacrifices only the surface diseased bone and preserves normal bone
- Imparts a more normal sensation
- The joint is likely to last longer even in younger and active patients.
- Earlier and faster rehabilitation
- Less risk of dislocation
- Easier to revise if needed.
- No leg length discrepancy.
In summary a Hip Resurfacing offers several advantages in young patients in young patients.
Avascular necrosis or Osteonecrosis is a fairly common hip condition.
Young patients are affected. Some of the causes leading to osteonecrosis are steroid intake, alcoholism, connective tissue disorders like SLE, Sickle cell disease, hypertension, decompression sickness, thrombosis, In a large number of individuals the cause is unknown or Idiopathic. Young and middle aged patients are affected. Involvement of both hips is fairly common.
Hip AVN
Hip showing advanced changes of avascular necrosis
Diagnosis- It takes a long time for the bony changes to be visible on plain x rays.
MRI scans and nuclear bone scans reveal the diagnosis early on when the condition is suspected. Both hips need to be imaged simultaneously. CT scans help to identify the extent of the bony involvement.
Treatment
The treatment depends on the stage of the disease. Most often conservative or non operative measures fail. Surgical treatment ranges from core drilling to total hip replacements. In the early stages core drilling can lead to a positive result in a good proportion of cases.
When this has failed, or the stage is more advanced, hip resurfacing is advised. However the surgeon should do so after a diligent assessment of the extent of disease. Hip resurfacing can be done when the extent of the femoral head involvement is less than 30 percent. In early cases partial hip resurfacing can be done in a few selected centers
Hip resurfacing operation
The presence of cysts makes hip resurfacing more difficult to perform with confidence. In these cases there are two options.
One is the Proxima hip replacement
where the bone is amputated at the base of the head similar to the BMHR. Then a short stem is impacted into the top portion or Proximal part of the neck and metaphysis of the femur. This has a large ball of the same diameter as the natural femoral head. The socket is also lined with a metal cup. Thus a trunnion of large diameter metal on metal results. The advantages are stability and less bone loss. The Proxima hip has a ten year follow up in the hands of its designer surgeon.
The other option is the Mid head resection Birmingham hip or BMHR.
Birmingham Mid head resection prosthesis
This operation involves amputating almost the entire head of the femur containing the cysts, impacting a conical stem into the neck portion of the femur and attaching a Birmingham hip like prosthesis. The cup also gets a metal liner.
All the options mentioned are bone sparing options.There is not much difference in the extent of the bony resection in the Proxima hip replacement and the Birmingham Mid head resection prosthesis. The former has a longer follow up.
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