AVASCULAR NECROSIS “ PRO HBO Indications List

“PRO” Argument
AVASCULAR NECROSIS
HBO Indications List
NE Chapter Presentation
Norma L. Cooney, MD, FACEP
Presented to UHMS HBO Therapy Committee
Sarah Parks, MD
Heather Murphy-Lavoie, MD
Tracy Leigh LeGros, MD, PhD
DEFINITION OF AVN

Definition: temporaryy or permanent loss of blood
supply to a bone resulting in the death of bone cellular
p
- marrow,, fat,, and mineralized tissue
components

Joint Involvement: occurrence near a joint can collapse
leading to collapse of the joint surface and disabling
arthritis

Final Common Pathway: of several disease entities
which impair blood supply to the bone
PATHOPHYSIOLOGY
Interruption of Blood Flow

Early Cell Death: hematopoetic cells, fat
cells and osteocytes - painless

Compartment Syndrome: cytogenic edema
and inflammation within enclosed space
(pain with negative films)
PATHOPHYSIOLOGY
Interruption of Blood Flow

R
Remodeling
d li Phase:
Ph
I b l
Imbalance
d
develops
l
* Osteocytes
y have high
g oxygen
yg requirements
q
for
normal function. In a hypoxic environment the rate
of bone resorption exceeds the rate of repair.
repair
* Multipotential Mesenchymal Cells in the marrow fail

tto differentiate
diff
ti t into
i t osteoblasts
t bl t iin a hypoxic
h
i
environment
Fi l O
Final
Outcome:
t
new immature
i
t
bone
b
iis weaker
k than
th
mineralized (dead) bone; collapse of the femoral head
occurs with repeated “body
“
weight loading””
ETIOLOGIC GROUPINGS



Idiopathic:
Idi
thi usually
ll ffemorall hhead;
d
occurs w/o underlying disease
Post-Traumatic: fracture
f
off
scaphoid, lunate, talus, or femur
neckk (30% - 50% progress tto AVN)
Secondary: environmental
pressure (divers
(di
& caisson),
i
)
alcoholism, steroids, radiation,
ESRD gout
ESRD,
gout, hemoglobinopathies
hemoglobinopathies,
SLE, arteriosclerosis, Cushings,
pancreatitis etc
pancreatitis,
etc.






IDIOPATHIC AVN
Involvement: any bone
Bilateral: 30% - 80%
Most Common: FH
Numbers: 10 K – 20 K
new FHN cases p
per
annum in the USA
Gender: M : F = 8 : 1
Age: 30 – 60 years( 75%)
25% are < 25 yy/o
WHY THE FEMORAL HEAD?



Most Vulnerable: the femoral head lies at the most remote
area of the skeleton’s vascular tree
N C
No
Collateral
ll t l Back-Up:
B k U th
the subchondral
b h d l bbone iis supplied
li d
by end arterioles that fan out as they approach the end of
the bone
Heavy Load: FH is subjected repeated body weight loading
DIAGNOSIS OF AVN

Radiographs: mineralized changes on x-ray lag
2 - 4 months behind the insult; lose precious time to treat

Bone Scan: sensitive but not anatomically detailed


MRI = GOLD STANDARD
S iti specific
Sensitive,
ifi and
d reliable
li bl b
basis
i ffor
staging by anatomic details
The basis of Steinberg Staging
Bilateral MRI is Mandatory
STEINBERG CLASSIFICATION
FICAT CLASSIFICATION
MRI Findings
Natural History
FICAT CLASS
TREATMENT OF AVN



Preservation: sphericity of the femoral head
 Marrow Pressure: to prevent further necrosis
 Vascularity
STAGE ONE DISEASE NATURAL HISTORY
70% - 80% of patients will progress
to FH collapse without intervention
HYPERBARIC OXYGEN THERAPY
HBO is aimed at STAGE 1 & 2 disease.
HBO cannot reverse subchondral fxs or FH collapse.
TREATMENT OF AVN – NO CONSENSUS


Conservative
 NWB / ROM
NSAID
NSAIDs
Medical / Non-Invasive
 Bisphosphonates
 Electromagnetic
g
Shock Wave
Electrical Stimulation
Stem Cell Injections
j

Core Decompression
 Bone Graft
Marrow Injection
 Cement
Electrical Stimulations
 Free Vascularized Fibular Graft Shock Wave

Re-Alignment Osteotomy
TOTAL HIP ARTHROPLASTY (THA)





THA Required: for > Stage 3
((articular surface damaged)
g )
AVN Survival Statistics: worse than for any other
group; 67% failure at 16 years (men < 50 y/o - Cigna)
THA Damage: greater than the original insult
Revisions Required: younger patients have an
almost absolute certainty they will need a revision
THA Redo Surgery: fraught with complications and
suboptimal outcome
PSYCHOSOCIAL BURDEN OF AVN







Afflicts the Young: should be productive citizens
Chronic Pain and Disability: interferes with work &
socializing
Lost Independence
Multiple Major Orthopedic Surgeries: for many
Financial Hardship
Depression, Anxiety, and Stress
Burden to Family
BENEFITS OF HBO
Reduces: marrow edema
 Increases O2 Delivery:
y to ischemic cells; thus relieving
g the
compartment syndrome and preventing further necrosis
 Significant Pain Relief: from  marrow pressure (20 txs)
 Stimulates Angiogenesis
 Stimulates Oxygen Dependent Cells: osteoclast and
osteoblast function for remodeling & repair
 Stimulates Multi-Potential Fibroblasts: in the marrow to
become osteogenic and form bone; when the O2 tension is
low these cells produce cartilage. Reverses the Imbalance

HUMAN STUDIES
(Strauss, et al.)




Meta Analysis (1998):
Meta-Analysis
4,224 patients with
St
Stage
11, 2 or 3 di
disease
Natural History Group (no tx):
842 (20%) Long Term Success ( > 24 months) = 32%
All Type Orthopedic Interventions: 3,193 (76%)
Long Term Success = 66%
H
Hyperbaric
b i Oxygen
O
Th
Therapy: 189 (4%)
Long Term Success = 81%
Strauss M , Dvorak T. Femoral Head Necrosis & HBOT. In Kindwall EP, Whelan HT eds.
Hyperbaric Medicine Practice 3rd Ed. Best Publishing Co. 2008.
HUMAN STUDIES
Reiss, et al.






Case Series
C
S i with
ith M
Matched
t h dC
Control
t lG
Group: 12 patients
ti t
Steinberg Stage 1 AVN (16 hips)
Age Range: 19 – 54 years
Treatment: all HBO patients received 100 Sessions
2 - 2.4 ATA 100% O2 (90 minutes)
HBO P
Patients:
ti t 81% reverted
t d to
t a normall MRI
HBO Failures: 1 p
pt with SLE / Steroids & 1 ESRD p
pt
Matched Control Group: 17% reverted to normal MRI
Reis et al. HBOT for Stage 1 Avascular Necrosis of the Femoral Head.
Journal of Bone & Joint Surgery (Br) 2003
HUMAN STUDIES
Montanari, et al.





Case Series:
C
S i
109 cases FHN
FHN, Ficat
Fi t St
Staged
d
Imaging
g g Studies: MRI’s before and after treatment
HBO Patients: 20 - 60 sessions @ 2.2 ATA (90 min)
Results: 94% HBO group (Ficat Stage < 2) recovered
completely
Conclusions: early diagnosis and HBO allows for
nearly complete recovery of FN AVN; no reason to treat
patients with Ficat Stage > 2 lesions
Montanari M, Bronzini N. Clinica Ortopedica e Traumatoligica Universita
Montanari
M Bronzini N Clinica Ortopedica e Traumatoligica Universita
degli Studi di Verona & Istituto Iperbarico, OTI Medicale, Vicenza, Italy (2003)
HUMAN STUDIES
Schwartz, et al.





Case Matched Series: 16 Stage 1 AVN hips treated
with HBO & NWB
HBOT Patients: 15 (idiopathic AVN); 1 SLE patient
(on steroids)
Control Group: 16 AVN matched hips
Results: HBOT patients registered > 90% total
resolution / reduction of subchondral lesion size
Single Failure: the lupus case
Schwartz O, Militianu D, Levin D, Norman D, Ramon Y, Shupak A, Melamed Y, Zinman C, Reis ND.
Israel (2003)
HUMAN STUDIES
Camporesi, et al.




Double Blind, Randomized, Controlled, Prospective
Study: 20 patients (no co-morbidities)
co morbidities)
Classification: Ficat Stage 2 disease
Treatment Groups:
 10 patients received HB Air (60 minutes)
 10 patients received HB Oxygen (60 minutes)
Evaluations: Pain & ROM at 10, 20, 30 treatments
Camporesi EM, et al. Hyperbaric Oxygen therapy in Femoral head Necrosis
Journal of Arthroplasty Vol. 25 No. 6 Suppl. 1 2010
HUMAN STUDIES
Camporesi, et al.



Results:
R
lt HBO Patients
P ti t had
h d significantly
i ifi tl  pain
i and
d
 ROM after 30 treatments
Study Suspended: all patients offered HBO
 19 patients went on to receive 90 HBO treatments
 17 patients reported for 7 year follow-up
Outco es aall were
Outcomes:
e e pa
pain free
ee with
t no
o  in ADLss
 None Received THA
 None Developed Contralateral Disease
 This is STAGE 2 100% Success!
Camporesi EM, et al. Hyperbaric Oxygen therapy in Femoral head Necrosis
Journal of Arthroplasty Vol. 25 No. 6 Suppl. 1 2010
ORTHOPEDIC SURGICAL DISADVANTAGES



Less Efficacious
Bilateral Interventions: two surgeries
 Bone Damage: to the femoral neck & trochanter
beyond the AVN damage
 Core Decompression: hip fracture rate up to 17%
 FVFG: 17% complication rate
(donor site, DVT, infection, microvascular)
 Osteotomy: so much femur damage that there is
great
g
eat d
difficultly
cu t y in pe
performing
o
g a f/u
/u THA
THE HBO ADVANTAGE








High Efficacy
Bilateral “Two-Fer”: approximately ½ the patients
Durable
“Preserves Bone Stock”: does not extend the injury
Painless
Financially Feasible: breadwinners might still keep
working during treatment
Non-Invasive: low risk of serious complications
Improvement: starts with 1st day of treatment
COST COMPARISONS

HBO Therapy:
$18,000
$18
000 - 39,000
39 000 (60 sessions)
$27,000 - 58,000 (90 sessions)

THA Surgery:
$45,000
$45
000 - $65,000
$65 000
not considering
g bilateral disease,
likely revisions, & increased
morbidity.
bidit
Costs based on 3rd Party Payors & negotiated fees.
THERAPEUTIC LOGIC
Stage 1 and 2 AVN = Physiologic Disease
Ischemia Compartment Syndrome
Hypoxia Dysfunctional Osteocytes
HBO is a Physiologic Cure
Stage
g 3 or greater
g
AVN = Structural Problem
Orthopedic Intervention Appropriate
Please Consider Adding
g
Stage 1 & 2 AVN
To the Indications List
Questions?
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REFERENCES
Aiello MR, et al. Imaging in Avascular Necrosis
emedicine.medscape.com/article/386808-overview
di i
d
/ ti l /386808
i
1-29
1 29
Bove and Davis Diving Medicine 4th Edition 2004 Chapter 21
Bejar J, et al. Vascular deprivation-induced osteonecrosis of the rat femoral
head as a model for therapeutic trials Theoretical Biology & Medical Modeling
2005. 2:24
Boss JH et al. Experimentally gained insight – based proposal apropos the
treatment of osteonecrosis of the femoral head Medical Hypothesis (2004) 62
62,
958-965
Banerjee A, et al. Avascular Necrosiswww.med.harvard.edu/JPNM/
BoneTF/Case13/Writeuo13.html
Camporesi, et al. Hyperbaric Oxygen Therapy in Femoral Head Necrosis The
Journal of Arthroplasty Vol 25 No. 6 2010
Jain K.K. Textbook of Hyperbaric
yp
Medicine 5th Edition 2009 Chapter
p
30
Kindwall and Whelan Hyperbaric Medicine Practice 3rd Edition2008 Chapter 34
Montanari M, Bronzini N. Indication About Hyperbaric Treatment of Aseptic
Necrosis Of the Femoral Head ((NATF)) Clinica Ortopedica e Traumatoligica
g
Universita degli Studi di Verona & Istituto Iperbarico, OTI Medicale , Vicenza
Italy.
REFERENCES




Reis, et al. Hyperbaric oxygen therapy as a treatment for Stage 1 avascular
necrosis of the femoral head J Bone & Joint Surgery (BR) 2003;85-B:371-5
Schwartz O, et al. Research on Avascular Necrosis of Femoral Head Dept.
Orthopaedics, Bnai Zion,Med> Center, Haifa; MRI Unit, Dept. Radiology,
Rambam Med. Center; Dept. Ortopaedics B, Rambam Med Center; RambamElisha Hyperbaric Medical Unit, Haifa; Marine Medicine Institute, Zahal,
Israel.
Vezzani, et al. http://archive.rubicon-foundation.org/1641
Vande Berg et al. Idiopathic Bone Marrow Edema Lesions of the Femoral
Head: Predictive Value of MR Imaging Findings Radiology August 1999Vol
212 No 2:527-535.