New trends in Avascular Necrosis of the Femoral Head' Natural evolution and dead bone rehabitation

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New trends in Avascular Necrosis of the Femoral
Head. Natural evolution and dead bone
rehabitation

• Carlo Della Rocca
• Department of Experimental Medicine
• Sapienza University of Rome
• Polo Pontino - Latina - Italy

EFORT, Vienna 2009
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Avascular necrosis of femoral headClassification

• idiopatic
• adult type
• yung type (Legg-Calvè-Pertes)
• traumatic
• steroid induced
• disbarism induced
• haemoglobinopathies induced
• radiation induced
• during neoplasic diseases

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Avascular necrosis of femoral headEtiopathogenesi
s
Avascular necrosis Ischemic damage
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Results
Round ligament artery
Lateral circumflex femoral artery
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Avscular necrosis of femoral head Pathology
Gross patology features are different depending
on the laggtime between the beginning of the
disease and the observation they are not
dependent from the etiology of the lesion
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Avascular necrosis of femoral head Pathology
Also the histologic features depend on the
laggtime between the beginning of the disease and
the observation, but they can vary depending on
the etiology of the lesion
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Unfavourable histologic evolution in the
avascular necrosis of the femoral head without
treatment
pre-clinical phase

• marrow and bone cells necrosis

• microfractures and fibrous demarcation of the
  necrotic area
• perilesional sclerotic border creation
• flattening and degenerative lesions of articular
  cartilage

clinical phase
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Favourable histologic evolution in the avascular
necrosis of the femoral head without treatment

• marrow and bone cells necrosis

pre-clinical phase

• microfractures (not always present) and
  granulation tissue deposition at the border of
  the necrotic area.
• creeping replacement
• partial or total dead bone rehabitation

clinical phase
clinical healing
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Avascular necrosis of femoral head Factors
predisponing to favourable evolution

• Moderate extension of the necrotic area
• Low mobility of the necrotic bone segment
• Treatment of the underlying disease or removal
  of the noxa patogena in the secondary types

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Avascular necrosis of femoral head Factor
determining the favourable evolution
creeping replacement or creeping substitution
Barth Phemister
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Avascular necrosis of femoral head Rationale for
the treatment
To avoid peri-lesional sclerosis formation and
favour the creeping replacement to allow the
maximum of the necrotic bone segment
rehabitation to be reached
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Avascular necrosis of femoral head Therapy

• Non weight bearing
• Treatment of the underlying disease or removal
  of the noxa patogena in the secondary types

Avoiding the peri-lesional sclerosis formation
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Avascular necrosis of femoral head Therapy

• Magnetic fields
• Core decompression and autologous bone grafting

Fovouring the creeping replacement
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Avascular necrosis of femoral head Therapy
Prof. Anna Maria Patti Virology and Cell Culture
Lab
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Avascular necrosis of femoral head Therapy
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Avascular necrosis of femoral head Insufficient
repair

• Lack of remodeling
• Destructive remodeling
• Reconstructive remodeling

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Avascular necrosis of femoral head Therapy (the
close future)
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Avascular necrosis of the femoral head Conclusion
Avascular necrosis of the femoral head is a
multiple etiology disease with ischemic
pathogenesis in which the mechanical situation of
the necrotic bone segment often leads to
microfractures which can cause its mobilization
and consequent demarcation from the viable bone
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Avascular necrosis of the femoral head Conclusion
The histopathology based rationale of the
treatment of the disease is to avoid the necrotic
bone segment demarcation and favour its
rehabitation and subtitution by new formed bone
coming from the adjacient viable bone. In
cases with insufficient repair stem cell
implant using threedimensional scaffold can be
postulated in the very close future.
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Thank you