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RADIOLOGY REVIEW 1.0 ANCC Contact Hours Avascular of the

Patrick Graham

Introduction tramadol, with minimal relief noted. With this, it was recommended he be evaluated by orthopaedics. of bone (AVN), also known as oste- Upon presentation, the patient was alert, oriented, onecrosis, ischemic necrosis, or aseptic necrosis, is a and affect appropriate. He was in no apparent distress. progressive pathological process in which compromise His BMI (body mass index) was calculated at 37.2. He of bony vasculature results in of osseous tissue ambulated with an antalgic, Trendelenburg-type gait and cells ( Jones & Mont, 2014 ; National without use of an assistive device. He postured with a Institutes of Health, 2015 ). This process eventually leads right trunk lean, offsetting his from the left, with to bony collapse, destruction of the associated , and coming into adduction. There was no appreciable development of arthritis (Jawad, Haleem, & Scully, deformity, discoloration, or swelling. He endorsed ten- 2012 ; Jones & Mont, 2014 ; Karantanas, 2013 ; National derness anterior as well as lateral. Range of motion was Institutes of Health, 2015 ). Although the exact incidence limited by pain and body habitus. was noted and prevalence are unknown, it is estimated that up to radiating into the groin, with end-range fl exion, abduc- 20,000 new cases of AVN are reported in the United tion, and internal rotation. There was no appreciable States annually ( National Institutes of Health, 2015). instability. Strength was grossly equal, with noted glu- Etiological factors associated with AVN are divided teal weakness of both . The patient reported left hip into traumatic and atraumatic. The most common trau- discomfort with resisted motion. He was found to be matic incident related to AVN of the hip is femoral neck distally neurovascularly intact. He displayed a positive fracture (Jones & Mont, 2014 ; National Institutes of c-sign, hip scouring, FABER, FADIR, anterior Health, 2015 ). Signifi cantly complex fracture geometry Stinchfi eld’s with a negative straight leg raise. and displacement have been identifi ed as increasing the Radiographs of the left hip were evident for CAM de- risk of developing AVN ( Barquet, Mayora, Guimaraes, formity, joint space narrowing, marginal osteophytes, and Suarez, & Giannoudis, 2014; National Institutes of sclerotic changes (see Figure 1 ). These fi ndings, in the Health, 2015 ). Even with optimal surgical management, context of the patient’s age and reported alcohol abuse, a small percentage of patients will go on to develop AVN were concerning for avascular necrosis of the femoral within 2 years of operation (Barquet et al., 2014). head. With this, it was recommended the patient have fur- Atraumatic causes include chronic alcohol abuse, cig- ther evaluation by magnetic resonance imaging (MRI). arette smoking, chronic use of , sickle cell Magnetic resonance imaging is proven more sensi- disease, systemic erythematous, chronic renal fail- tive for assessing the subtle osseous changes seen with ure, human immunodefi ciency virus infection, pancrea- AVN and is unanimously considered to be the gold titis, chronic hyperlipidemia, exposure to radiation, and standard for evaluating early-stage disease (Jones & thrombophlebitis ( Jones & Mont, 2014 ; National Mont, 2014; Manenti, Altobelli, Pugliese, & Tarantino, Institutes of Health, 2015 ). Still others are idiopathic. 2015 ). It is also a validated method for imaging follow- Chronic alcohol abuse and use of corticosteroids are as- up in those patients being treated conservatively sociated with approximately 80% of atraumatic cases (Manenti et al., 2015). This patient’s magnetic reso- (Jones & Mont, 2014). nance image displays the classic osseous changes asso- ciated with AVN, seen as a well-demarcated, focal lesion Case Presentation of the superior femoral head (see Figure 2). A 47-year-old man presented with “years” of gradually worsening left hip pain. He denied any injury or inci- Management dent but did endorse two decades of alcohol abuse, The management of avascular necrosis ranges from noted as approximately “six to eight drinks” daily and conservative to surgical depending on the severity of “more sometimes” on the weekends. He described an disease state and patient symptoms ( Jones & Mont, aching, sometimes throbbing, sensation of the hip, which had been worsening for more than a year. He Patrick Graham, MSN, RN, ANP-BC, Department of , noted a progressive . He initially found relief with Northwestern Medicine, Chicago, IL. over-the-counter medications such as Advil (ibuprofen) The author has disclosed that he has no fi nancial interests to any and Tylenol (acetaminophen), but those were reportedly commercial company related to this educational activity. no longer effective. More recently, he was prescribed DOI: 10.1097/NOR.0000000000000313

62 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 © 2017 by National Association of Orthopaedic Nurses Copyright © 2017 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. F IGURE 1. Anteroposterior and lateral views of the left hip showing CAM deformity, joint space narrowing, marginal osteophytes, and dense sclerotic changes.

2014 ; National Institutes of Health, 2015). Nonoperative/ 2015 ). Unfortunately, these measures are ineffective in conservative interventions are primarily focused on halting the progression of disease, although they have symptom management and include weight-bearing pre- shown promise in slowing progression while better cautions, activity modifi cation with the avoidance of managing the associated symptoms (Jones & Mont, high-impact activities, stretching program, and use of 2014 ; National Institutes of Health, 2015). analgesics and other pharmacotherapies such as bis- Surgical management entails procedures that are phosphonates, statins, anticoagulants, and vasodilators joint preserving versus joint replacing. Joint-preserving (Jones & Mont, 2014; National Institutes of Health, procedures include core , ,

F IGURE 2. Coronal T1 of pelvis.

© 2017 by National Association of Orthopaedic Nurses Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 63 Copyright © 2017 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. bone marrow grafting, various nonvascularized bone as well as evaluate for other potential causes of hip pain grafting techniques, as well as those incorporating vas- ( Jawad et al., 2012 ; Jones & Mont 2014 ; Karantanas, cularized fi bula (Jones & Mont, 2014 ; Mohanty, Singh, 2013 ). Further investigation into the routine clinical use Kundangar, & Shankar, 2016 ; National Institutes of of advanced imaging techniques such as MRI, com- Health, 2015). The primary goal in early stages of dis- puted tomography, and nuclear medicine bone scan is ease, especially in the younger population, is preserving still needed ( Manenti et al, 2015). There is also lacking the femoral head and native joint and thus is better consensus as to an ideal classifi cation system for early- treated with one of these interventions (Jawad et al., stage AVN, an area that warrants further research 2012 ; Mohanty et al., 2016). A lack of prospective rand- ( Jawad et al., 2012; National Institutes of Health, 2015). omized trials, as well as variable reported success rates of these surgical procedures, begs the questions as to REFERENCES the true effi cacy or any superiority of the various tech- Barquet , A. , Mayora , G. , Guimaraes , J. M. , Suarez , R. , & niques available (Jawad et al., 2012; Jones & Mont, Giannoudis , P. V. (2014 ). Avascular necrosis of the 2014 ; National Institutes of Health, 2015). femoral head following trochanteric fractures in The other surgical option is total hip , a adults: A systemic review. Injury , 45 ( 12 ), 1848 – 1858 . joint-replacing procedure. Recent studies indicate ex- Jawad , M. U. , Haleem , A. H. , & Scully , S. P. (2012 ). In brief: Ficat classifi cation: Avascular necrosis of the femoral cellent long-term results, as comparable with outcomes head . Clinical Orthopaedics and Related Research , in patients with , for those with AVN un- 470 ( 9 ), 2636 – 2639 . dergoing total hip arthroplasty (Jones & Mont, 2014; Jones , L. , & Mont , M. (2014 ). Osteonecrosis . UpToDate . National Institutes of Health, 2015 ). The revision rate Retrieved from https://www.uptodate.com/contents/ has decreased to about 3% and is most commonly as- osteonecrosis-avascular-necrosis-of-bone sociated with loss of fi xation of the acetabular compo- Karantanas , A. H. (2013 ). Accuracy and limitations of diag- nent secondary to wear ( Jones & Mont, 2014; National nostic methods for avascular necrosis of the hip . Institutes of Health, 2015 ). Expert Opinion on Medical Diagnostics , 7 ( 2 ), 179 – 187 . Manenti , G. , Altobelli , S. , Pugliese , L. , & Tarantino , U. ( 2015 ). The role of imaging in diagnosis and manage- ment of femoral head avascular necrosis. Clinical Discussion Cases in Mineral and Bone , 12 ( 1 ), 31 – 38 . Avascular necrosis of the femoral head should be con- Mohanty , S. P. , Singh , K. A. , Kundangar , R. , & Shankar , V. sidered in the differential for any patient presenting ( 2016 ). Management of non-traumatic avascular ne- with hip pain and any of the reported risk factors. This crosis of the femoral head—A comparative analysis of case highlights the importance of collecting a thorough the outcome of multiple small diameter drilling and core decompression with fi bular grafting. Musculo- history and synthesizing information. When these risk skeletal Surgery . Abstract retrieved from https://dx.doi. factors are identifi ed, it should direct the advanced org/10.1007/s12306-016-0431-2 practice orthopaedic provider to obtain appropriate im- National Institutes of Health . (2015 , October). Questions aging workup for accurate diagnosis. With improved and answers about osteonecrosis (avascular necrosis ). MRI techniques, we are better able to investigate for ra- Retrieved from http://www.niams.nih.gov/health_Info/ diographically occult fi ndings seen in early-stage AVN, Osteonecrosis/

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64 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 © 2017 by National Association of Orthopaedic Nurses Copyright © 2017 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.