Avascular necrosis of the femoral head

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Avascular necrosis of the femoral head
Diagnosis in short

Necrotic bone in a case of AVN. H&E stain.

LM bone with empty lacunae (indicative of necrosis)
Site femoral head

Associated Dx +/-sickle cell disease
Clinical history +/-oral steroids, +/-radiation
Symptoms pain
Prevalence uncommon
Prognosis benign

Avascular necrosis of the femoral head is necrosis of the head of the femur to the vascular compromise.

It is often just referred to as avascular necrosis, abbreviated AVN.

In children idiopathic AVN of the of capital femoral epiphysis is known as Legg–Calvé–Perthes disease.[1]

General

Risk factors:

Clinical:

  • Pain.[4]
  • Locking.[5]
  • Catching.

Gross

Features:[6]

  • Wedge-shaped pale yellow abnormality below cartilage.
  • +/-Cartilage separates from the bone.
  • +/-Deformation of femoral head.

Image:

Microscopic

Features:[7]

  • Empty lacunae - indicative of necrotic bone (osteonecrosis).
  • Degnerative changes of the cartilage overlying the necrotic bone.[4]

DDx:

Images

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FEMORAL HEAD, RIGHT, HIP ARTHROPLASTY: 
- AVASCULAR NECROSIS OF THE FEMORAL HEAD.

AVN and degenerative joint disease

FEMORAL HEAD AND JOINT CAPSULE, LEFT, HIP ARTHROPLASTY:
- AVASCULAR NECROSIS OF THE FEMORAL HEAD.
- DEGENERATIVE JOINT DISEASE WITH MILD SYNOVITIS AND VILLOUS HYPERPLASIA.
- NEGATIVE FOR MALIGNANCY.
FEMORAL HEAD AND JOINT CAPSULE, RIGHT, HIP ARTHROPLASTY:
- AVASCULAR NECROSIS OF THE FEMORAL HEAD.
- DEGENERATIVE JOINT DISEASE.
- BENIGN JOINT CAPSULE TISSUE.
- NEGATIVE FOR MALIGNANCY.

Remote AVN

FEMORAL HEAD AND JOINT CAPSULE, LEFT, HIP ARTHROPLASTY:
- FEMORAL HEAD WITH DEGENERATIVE JOINT DISEASE AND MARKED DEFORMATION CONSISTENT WITH A HISTORY OF
AVASCULAR NECROSIS.
- JOINT CAPSULE WITH MINIMAL CHRONIC INFLAMMATION.

Micro

The sections show a femoral head with loss of cartilage and focal vertical cleft formation in the remaining thinned cartilage. Subchondral sclerosis is present. The underlying bone is viable. Bone marrow is present. The red blood cells have a sickled morphology.

Joint capsule tissue with focal lymphocytes and plasma cells is present.

Remote AVN with focal lesion

FEMORAL HEAD AND SURROUNDING TISSUE, RIGHT, HIP ARTHROPLASTY:
- FOCAL DEGENERATIVE CHANGES OF THE CARTILAGE WITH AN UNDERLYING WEDGE OF FIBROSIS 
  AND REMODELLED BONE COMPATIBLE WITH A HISTORY OF AVASCULAR NECROSIS.
- DEGENERATIVE JOINT DISEASE.
- BENIGN FIBROADIPOSE TISSUE AND CARTILAGE.
- NEGATIVE FOR MALIGNANCY.

See also

References

  1. Shah H (January 2014). "Perthes disease: evaluation and management". Orthop. Clin. North Am. 45 (1): 87–97. doi:10.1016/j.ocl.2013.08.005. PMID 24267210.
  2. URL: http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/osteonecrosis/osteonecrosis.html. Accessed on: 30 April 2012.
  3. Al Omran, A. (May 2013). "Multiple drilling compared with standard core decompression for avascular necrosis of the femoral head in sickle cell disease patients.". Arch Orthop Trauma Surg 133 (5): 609-13. doi:10.1007/s00402-013-1714-9. PMID 23494112.
  4. 4.0 4.1 Magnussen, RA.; Guilak, F.; Vail, TP. (May 2005). "Cartilage degeneration in post-collapse cases of osteonecrosis of the human femoral head: altered mechanical properties in tension, compression, and shear.". J Orthop Res 23 (3): 576-83. doi:10.1016/j.orthres.2004.12.006. PMID 15885478.
  5. McCarthy, J.; Puri, L.; Barsoum, W.; Lee, JA.; Laker, M.; Cooke, P. (Jan 2003). "Articular cartilage changes in avascular necrosis: an arthroscopic evaluation.". Clin Orthop Relat Res (406): 64-70. doi:10.1097/01.blo.0000043045.84315.d9. PMID 12579001.
  6. Lester, Susan Carole (2005). Manual of Surgical Pathology (2nd ed.). Saunders. pp. 224. ISBN 978-0443066450.
  7. Steffen, RT.; Athanasou, NA.; Gill, HS.; Murray, DW. (Jun 2010). "Avascular necrosis associated with fracture of the femoral neck after hip resurfacing: histological assessment of femoral bone from retrieval specimens.". J Bone Joint Surg Br 92 (6): 787-93. doi:10.1302/0301-620X.92B6.23377. PMID 20513874.
  8. Fondi, C.; Franchi, A. (Jan 2007). "Definition of bone necrosis by the pathologist.". Clin Cases Miner Bone Metab 4 (1): 21-6. PMID 22460748.