Which reconstruction procedures are performed in the treatment of femoral head avascular necrosis (AVN)?

Updated: Oct 22, 2018
  • Author: John D Kelly, IV, MD; Chief Editor: Craig C Young, MD  more...
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Answer

Reconstruction procedures

  • Despite aggressive management, most hips that undergo collapse ultimately require reconstruction (ie, replacement). Prosthetic replacement offers the most predictable means of pain relief in advanced AVN; however, many arthroplasty options are available to meet the challenge of painful arthropathy in younger patients. [18]

  • Femoral resurfacing arthroplasty is gaining acceptance for younger patients. [18] Both the femoral head and acetablum are "resurfaced" with metal, indicating minimal bone resection. This procedure circumvents the problem of polyethylene wear. However, technical and design problems with surface replacements may explain the relatively high failure rate in some clinical series. [19] Nonetheless, refinements in both technique and design predict improved outcomes.

  • Resurfacing arthroplasty remains a controversial procedure that likely will not last a patient’s lifetime. Current recommendations are that resurfacing is contraindicated if the avascular area exceeds one third of the femoral head. Furthermore, there is a 1% incidence of femoral neck fracture with this procedure. Lastly, the issue of metal ion release has spurred much debate, although there are no good data available to suggest injurious effects. Fortunately, resurfacing arthroplasty likely confers no significant compromise for subsequent arthroplasty.

  • A report on preliminary clinical results of 5 subjects who underwent a total of 7 focal anatomic-resurfacing implantation procedures for the treatment of osteonecrosis of the femoral head, found that the alternative technique of focal anatomic hip resurfacing yielded preliminary successful results at 2+ year follow-up. [20]

  • Bipolar arthroplasty theoretically decreases shear stress and impact load on acetabular cartilage, although this concept has not been born out clinically. [18] Persistent groin pain, high rates of polyethylene wear, and early loosening have mitigated the appeal of this option. Resection arthroplasty should only be considered in very young patients and in debilitated patients who are at high risk for infection (eg, patients on dialysis).

  • Total hip arthroplasty is perhaps the most commonly performed and successful surgery for advanced AVN of the hip. However, clinical outcomes are inferior to those of total hip arthroplasty that is performed for osteoarthritis. Cementless prostheses with an improved design may afford increased longevity relative to cemented counterparts. Despite recent improvements in prosthetic replacement, replacement arthroplasty precludes further participation in impact activities (eg, running, jogging) because these activities greatly decrease implant longevity.


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