Managing Patients With AVN of the Hip

In order to achieve the best outcome, early accurate diagnosis and intervention is crucial. Once the deterioration begins, the structural integrity of the hip will become more unstable.1,2 There are several treatment modalities that may be used to slow the progression of the disease such as core decompression surgery and hip resurfacing arthroplasty.11,12 However, total hip replacement remains the gold standard in the management and treatment for AVN of the hip.11-13

Core decompression surgery is a newer surgical procedure compared with standard total hip replacement, and it has shown promising results.11 Unfortunately, the disadvantage of this procedure is that it is more suitable for patients with early stages of avascular necrosis. Core decompression relies on reducing the pressure between the head of the femur and the acetabulum while restoring vascular blood flow to slow the progression of the disease.11,13

Hip resurfacing arthroplasty is another option to prolong the life of the hip.12This procedure has been growing in popularity and has been associated with promising results. Like total hip replacement, hip resurfacing arthroplasty involves implanting an artificial prosthesis but preserves more of the natural bone.12,13 The head of the femur is preserved, and a metal implant (cap) is placed on top of the femoral head. This improves patient range of motion, allowing the patient to participate in more physical activities compared with a total hip replacement. As with a total hip replacement, patients will also need to undergo revision surgeries for a hip resurfacing arthroplasty, but the improvement in mobility is a tremendous benefit.12

Total hip replacement is a surgical procedure where the head of the femur is extracted, and an artificial prosthesis is implanted into the femur. This procedure is the most reliable in terms of immediate pain relief and has the quickest recovery time.11 Regrettably, due to physical incapability and limited range of motion following surgery, total hip replacement is undesired in many affected patients, and other treatments options are explored.11  


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Clinicians must also consider the young age of patients presenting with AVN of the hip. The patient’s lifespan will often exceed the longevity of the implant, which will lead to further revision surgeries later in life. Therefore, the recommendation for surgery is often rejected until it is absolutely necessary.12,13

Educating Patients Living With AVN of the Hip

Although there is a no cure for AVN of the hip, there are several treatment options that can reduce a patient’s pain and drastically improve his or her quality of life. The ultimate treatment goal is to prevent further progression of the condition. In terms of physical activity, patients should be advised to bear as minimal weight as possible on the affected joint. The use of a crutch, cane, or walker can assist in taking increased pressure off the joint and has shown to be effective in the early stages of AVN.14

Medications including bisphosphonate and anticoagulant drugs have been shown to be beneficial in the early stages of AVN. Bisphosphonates may inhibit osteoclastic activity, while anticoagulants have been shown to reverse the process of ischemia caused by hypofibrinolysis and thrombophilia.13

Unfortunately, depending on the patient’s current progression of disease, the success of these medications is unpredictable; patients must always be educated on the possibility of limited success. Comorbidities and medical history must be thoroughly evaluated and addressed before the patient can be considered for any of these medications.

While limited physical activity and prescribed medications may provide temporary relief, it is extremely important for healthcare providers to discuss with their patients the possible need for surgery in the future. There are many surgical options to consider, but — as outlined above — studies have shown that a total hip replacement is the most effective.13

Paul Lee, PA-C, is full time physician assistant; he received his Masters of Physician Assistant at August University in August 2020. Lisa Daitch, MPAS, PA-C, is an associate professor in the Physician Assistant Department of Augusta University, in Augusta, Georgia.

References

1. Narayanan A, Khanchandani P, Borkar RM, et al. Avascular necrosis of femoral head: a metabolomic, biophysical, biochemical, electron microscopic and histopathological characterization. Sci Rep. 2017;7(1):10721.

2. Graham P. Avascular necrosis of the femoral head. Orthop Nurs. 2017;36(1):62-64.

3. Scolaro JA, Marecek G, Firoozabadi R, Krieg JC, Routt MLC. Management and radiographic outcomes of femoral head fractures. J Orthop Traumatol. 2017;18(3):235-241.

4. Liu L-H, Zhang Q-Y, Sun W, Li Z-R, Gao F-Q. Corticosteroid-induced osteonecrosis of the femoral head: detection, diagnosis, and treatment in earlier stages. Chin Med J (Engl). 2017;130(21):2601-2607.

5. Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT Open Rev. 2019;4(3):85-97.

6. Cibulka MT, White DM, Woehrle J, et al. Hip pain and mobility deficits—hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2009;39(4):A1-A25.

7. Hoaglund FT. Primary osteoarthritis of the hip: a genetic disease caused by European genetic variants. J Bone Joint Surg Am. 2013;95(5):463-468.

8. Chiamil SM, Abarca CA. Imaging of the hip: a systematic approach to the young adult hip. Muscles Ligaments Tendons J. 2016;6(3):265-280.

9. Manenti G, Altobelli S, Pugliese L, Tarantino U. The role of imaging in diagnosis and management of femoral head avascular necrosis. Clin Cases Miner Bone Metab. 2015;12(Suppl 1):31-38.

10. Baig SA, Baig MN. Osteonecrosis of the femoral head: etiology, investigations, and management. Cureus. 2018;10(8):e3171.

11. Sadile F, Bernasconi A, Russo S, Maffulli N. Core decompression versus other joint preserving treatments for osteonecrosis of the femoral head: a meta-analysis. Br Med Bull. 2016;118(1):33-49.

12. Pyda M, Koczy B, Widuchowski W, et al. Hip resurfacing arthroplasty in treatment of avascular necrosis of the femoral head. Med Sci Monit. 2015;21:304-309.

13. Zalavras CG, Lieberman JR. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg. 2014;22(7):455-464.

14. Tripathy SK, Goyal T, Sen RK. Management of femoral head osteonecrosis: current concepts. Indian J Orthop. 2015;49(1):28-45.