Approach to Inflammatory Arthritis – Hip Osteonecrosis

– particularly relevant in SLE, rheumatoids; related most significantly to steroid use
– in general, the prognosis for the hip when the AVN is related to steroid use is EXTREMELY POOR!

– in patients with SLE – the outcome of THA is definitely not as good as age matched controls in other groups; it is extremely desirable to delay the need for THA in these patients.

Treatment Rationale:
– four treatments exist – core decompression, osteotomy, non-vascularized bone grafting, vascularized bone grafting. None of these work that well in the POST-collapse head.

– core decompression is useful for EARLY disease, pre-collapse, with SMALL LESIONS – makes it important to identify these patients early!
– osteotomy is only good for small lesions, and the results of it in steroid induced AVN is quite poor.
– non-vascularized bone grafting includes cortical grafting through the core decompression tract, grafting through a window in the femoral neck, and grafting through a trap-door in the articular surface. Overall, the results are marginal, probably reflecting the more advanced disease at this stage of treatment. If used, the lesions should be SMALL (less than 200o involvement of the head)
– vascularized bone grafting in larger lesions is probably good if you can get someone to do it.

– post-collapse – your options are limited. These are due for arthroplasty

As a note, AVN of the knees can also be treated with core decompression if early. Again, these patients are dangerously close to requiring TKA.

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