Avascular Necrosis of the Hip: Treatment and Recovery Options

Avascular necrosis of the hip joint?

Hello.
I was diagnosed with avascular necrosis of the femoral head at the end of May this year.
This condition occurred after I had a dislocation from a car accident five years ago, which required surgery to insert screws for stabilization.
The screws were removed over three years ago.
Six months ago, I began experiencing frequent pain in my left leg.
I consulted several orthopedic specialists and underwent X-rays, but they attributed my symptoms to postoperative complications.
It wasn't until I sought a second opinion at the end of May that a doctor discovered a crack on the lateral side of the femoral head, indicating collapse.
He mentioned that it would continue to collapse and that the necrotic bone would affect the healthy bone.
He does not recommend a hip replacement at this time and prescribed Fushenmei for me.
Will this medication benefit my bones? I am to take one pill a week.
Are there any side effects? Can I become pregnant while taking this medication? Why do doctors only rely on X-rays to make such conclusions? Are there no further advanced examinations available for avascular necrosis? Is it possible to remove the necrotic bone and regenerate new bone? Would a femoral osteotomy be suitable for me to reposition the abnormal area inward and the healthy area outward? What are the chances of regeneration? I want to save my hip joint...
Please help me.
My mobility is still okay for now, but knowing my condition makes me hesitant to walk or lift heavy objects...
Please assist me in saving my hip joint.

Juan, 20~29 year old female. Ask Date: 2006/06/10

Dr. Xu Zhenrong reply Physical Fitness

Dear Ms.
Juan,
Thank you for your inquiry.
The primary function of Fosamax (Alendronate) is to reduce the activity of osteoclasts in the bones and to decrease bone loss.
Generally, it is quite effective for patients with osteoporosis.
Common side effects include irritation of the esophagus and stomach, ulcers, nausea, vomiting, abdominal pain, and indigestion.
Other side effects may include hypocalcemia, joint pain, muscle pain, headaches, and rashes.
It is recommended to take the medication 30 minutes before breakfast with 240 cc of plain water, and you should not lie down or bend your abdomen for half an hour after taking the medication.
Regarding diagnosis: The examination for avascular necrosis of the femoral head primarily involves X-rays of the hip joint.
Other possible examinations include MRI (Magnetic Resonance Imaging), bone scans, and CT scans, which should be arranged by your clinician based on symptoms.
According to X-ray and MRI findings, avascular necrosis can be classified into six stages.
Stage one is relatively mild, with changes only visible on MRI; stage two shows patchy changes on X-ray; stage three presents with crescent signs; stage four shows flattening of the femoral head; stage five indicates narrowing of the hip joint space or changes in the acetabulum; and stage six represents severe osteoarthritis.
In terms of treatment: There is currently no completely satisfactory treatment for avascular necrosis of the femoral head, and prevention is better than treatment.
The goal of early detection and treatment is to delay deterioration and flattening of the femoral head.
1.
Conservative treatment: Using a cane or crutches primarily aims to reduce weight-bearing on the affected limb to alleviate pain.
Additionally, some have attempted various forms of electromagnetic stimulation for treatment, but results have been inconsistent.
2.
Surgical options:
A.
Decompression surgery involves drilling a hole in the femoral head to reduce the pressure in the bone marrow.
This is effective for stages one and two.
B.
Bone grafting is used to replace necrotic bone and has good results for early-stage patients, provided the femoral head has not yet collapsed.
However, it carries some complications, so careful case selection is necessary.
C.
Osteotomy involves rotating the non-necrotic femoral head to a weight-bearing area to replace the necrotic portion.
This surgical technique is more complex and has a lower success rate, which limits its use.
D.
Total hip arthroplasty: Late-stage treatment for stages four and above can be divided into partial hip replacement and total hip replacement.
Studies indicate that total hip replacement may yield better outcomes.
Due to advancements in technology and materials for artificial joints, the effectiveness of joint replacements for avascular necrosis is now comparable to that for other bone diseases.
Results are also quite favorable in younger patients, and the durability of artificial joints has significantly improved, making joint replacement surgery a commonly used treatment method.
The most suitable surgical approach depends on individual clinical symptoms and the extent of avascular necrosis, requiring case-by-case arrangements.
It is advisable to discuss your concerns in detail with your clinician to arrange the most appropriate examinations based on your symptoms and needs.
Wishing you all the best from the Rehabilitation Department of Taipei Hospital.

Reply Date: 2006/06/10

More Info

Avascular necrosis (AVN) of the hip, also known as osteonecrosis, is a condition that occurs when there is a loss of blood supply to the femoral head (the ball part of the hip joint), leading to bone death and potential collapse of the bone structure. This condition can arise from various causes, including trauma (such as dislocations or fractures), long-term use of corticosteroids, excessive alcohol consumption, and certain medical conditions like lupus or sickle cell disease.

In your case, it seems that your AVN may have been precipitated by the trauma from the car accident five years ago, which resulted in a dislocated hip and subsequent surgical intervention. The fact that you are experiencing pain and have been diagnosed with a crack in the femoral head suggests that the condition is progressing, and the risk of further collapse is significant.

Treatment Options
1. Conservative Management: Initially, your doctor may recommend conservative treatment options, which can include:
- Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation. The medication you mentioned, Fuzhengmei, may have benefits for bone health, but it’s essential to discuss its efficacy and potential side effects with your healthcare provider.

- Activity Modification: Limiting weight-bearing activities can help reduce stress on the hip joint and slow the progression of AVN.

- Physical Therapy: A physical therapist can guide you through exercises that strengthen the muscles around the hip and improve mobility without putting excessive strain on the joint.

2. Surgical Options: If conservative management fails and the condition worsens, surgical interventions may be necessary:
- Core Decompression: This procedure involves removing a small portion of the inner bone to relieve pressure and promote blood flow to the area.

- Bone Grafting: In some cases, bone grafting may be performed alongside core decompression to help restore the structure of the femoral head.

- Osteotomy: This procedure involves cutting the bone and repositioning it to redistribute weight and relieve pressure on the affected area.

- Total Hip Replacement: If the femoral head has collapsed significantly, a total hip replacement may be the most effective option, although your doctor has advised against it at this stage.

Recovery and Prognosis
The recovery from AVN treatment varies significantly based on the severity of the condition and the chosen treatment method. Early intervention tends to yield better outcomes. If you are considering surgical options, it’s crucial to discuss the potential risks and benefits with your orthopedic surgeon.

Regarding your concerns about pregnancy while taking medications, it is essential to consult your healthcare provider. They can provide guidance based on your specific situation and the medications you are taking.

Diagnostic Considerations
You mentioned that your doctors primarily relied on X-rays for diagnosis. While X-rays are useful for assessing bone structure, MRI scans are often more effective in detecting early changes in bone marrow associated with AVN. If you feel that your condition is not being adequately assessed, you might consider seeking a second opinion or requesting further imaging studies like an MRI.

Conclusion
AVN is a serious condition that requires careful management to prevent further joint damage. While there are treatment options available, the best course of action depends on the extent of the disease and your overall health. It’s crucial to maintain open communication with your healthcare team, express your concerns, and actively participate in your treatment plan. Your proactive approach to understanding your condition and seeking help is commendable, and with the right management, there is hope for preserving your hip joint function.

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