OSTEONECROZA

(capului femural*)

syn.
Necroz avascular Necroz aseptic Necroz ischemic

Def.:
Necroza ischemic a componentelor osului.
Nu este necesar consecina unui episod unic de dereglare a fluxului sanguin; dar a episoadelor repetitive de sistare/revascularizare.
Celulele hematopoetice sunt cele mai sensibile la anoxie, necroz dup 12h Celulele osoase (osteocite, osteoblati, osteoclaste) necroz n 12-48h Adipocitele mduvei osoase necroz n 5z.
Osteocondrit disecant

Infarctul osos vs. Osteonecroz

Osteonecroz epifiz (total, adesea segmentar) Necroz avascular diafiz i metafiz

Osteonecroza
(femur proximal/distal, humerus proximal)
Cavitatea medular a metafizei (infarct medular) Regiunea subcondral a epifizei (infarct subcondral)

Istoric
James Russell, 1794 primul a descris osteonecroza Munro, 1738 primul a descris osteonecroza capului femural 1835 Cruveilhier descrie schimbrile morfologice ale capului femural datorate sistrii fluxului sanguin Phemister, 1930 descrierea complet Chandler, 1948 boala coronar a oldului

Epidemiologie
10-18% din 500.000 artroplastii totale de old effectuate annual n SUA US 15.000 cazuri anual Japonia 2500-3300 cazuri anual Predilecie rasial sicklemie (africani, mediteranieni) Sex-ratio: 8M:1F, excepie: SLE Vrsta: decada 4 5 Bilateral 55% cazuri

Localizare
Femur: cap, condili Cap humeral Mandibul Oasele carpiene (scafoid, semilunar - Kienbock) Oasele metatarsiene (capul metatarsianului IIIFreiberg) Corpul talusului

Etiologie
Idiopatic (40% ) Alcoolism (20%; pn la 80% din cazurile atraumatice) Traumatic (luxaia capului femural, fractur intracapsular de col/cap femural) Endotoxic (Schwartzman) datorit bacteriemiei sistemice Hemoglobinopatii Hipercoagulabilitate Hipercorticism: endogen (Cushing), exogen (37%) smpt.6m-3y!!! LPL Hiperlipidemia SLE; IBD Carcinom metastatic Leucemie acut limfoblastic sau promieloblastic Sarcina Radioterapia Viral: HIV, Hepatit, CMV Disbaric

Etiologie
Osteonecroza = un grup multifactorial de boli care induc, posibil prin intermediul unei ci comune, necroza osoas.

Anatomie
Acetabulul acoper 40% din capul femural Cartilajul articular:
partea cea mai groas: aspectul PS 3mm se subiaz la marginile periferice i inferioare 0,5cm

Vascularizarea arterial a capului femural

Artere nutritive Artere foveale (la 1/3 pers. rmn competente) Artere retinaculare

Rx (BaSO4+decalcificare), 1988

Forma infarctului: triungiular clasic; ovoid; multifocal

Fiziopatologie
Ischemie, prin mecanisme variate, inclusiv:
ntrerupere mecanic a arterelor Tromboz Embolie Injurie a vasului (vasculit, radioterapie) Creterea presiunii intramedulare (sdr. de compartiment osos)

De ce acest model de localizare ?

Suprafa mare acoperit de cartilaj articular, prin care nu trec vasele Circulaie colateral limitat, imadecvat pentru a susine circulaia n lezarea cii principale

Histologic
Dispariia osteocitelor din lacunele osoase

Revascularizarea (extindere din osul sntos adiacent) determin:

Hiperemia esutului osos adiacent -> osteoporoz Resorbie osteoclasitc a segmentului necrozat -> colaps/fragmentare (n prezena ncrcrii mecanice) -> suprafa articular iregular (artrit degenerativ)

 Nu necroza, ns resorbia (component a procesului reparativ) induce pierderea integritii structurale, colaps subcondral i incongruena suprafeelor articulare.

Acuze i istoric
Debut insidios Durere localizat inghinal, fesa ipsilateral, genunchi sau regiunea trohanterului mare. Accentuarea durerii la portajul greutii

Obiectiv
Amplituda micrilor pasive e limitat, acestea sunt dolore, n special rotaia intern forat. Ridicarea piciorului mpotriva rezistenei e dolor Rotaia intern/extern pasiv a membrului inferior extins poate fi dureroas, care este datorat sinoviitei active.

DIAGNOSTIC IMAGISTIC

Radiografia
Lucen sucondral arciform n regiunea epifizar arii de pierdere a opacitii osoase (semnul semilunei/ engl:crescent).

Sectoare de radiolucen (resorbie ) i scleroz (apoziie de os nou pe trabeculele necrozate)

Aplatizarea capului femural

Colaps a capului femural stng

stage II plain film : mixed osteopenia &/or sclerosis &/or subchondral cysts, without any subchondral lucency (crescent sign).

stage III plain film : crescent sign & eventual cortical collapse

stage IV plain film : end stage with evidence of secondary degenerative change

Radiografie
Criterii adiionale:
Poziia Estimarea % volumului capului femural implicat (axial) Estimarea % suprafeei portante implicate (coronal) Efuzia articular Prezena unui fragment osteocondral potenial instabil

Ficat classification is used for AVN of the hip.

uses a combination on pain film, MRI and clinical features stage 0
plain film : normal MRI : normal clinical symptoms : nil

stage I
plain film : normal or minor osteopaenia MRI : oedema bone scan: increased uptake clinical symptoms: pain typically in the groin

stage II
plain film : mixed osteopenia &/or sclerosis &/or subchondral cysts, without any subchondral lucency (crescent sign - see below) MRI : geographic defect bone scan : increased uptake clinical symptoms: pain and stiffness

stage III
plain film : crescent sign & eventual cortical collapse MRI : same as plain film clinical symptoms : pain and stiffness+/- radiation to knee and limp

stage IV
plain film : end stage with evidence of secondary degenerative change MRI : same as plain film clinical symptoms : pain and limp

Steinberg has classified the radiologic appearance into 6 stages, as follows:

Stage 0: normal findings are demonstrated Stage I: the appearance may vary from normal to subtle trabecular mottling, but an isotopic bone scan or MRI shows abnormal bone Stage II: stage IIa - focal radiopacity is associated with osteopenia; stage IIb - radiopacity is associated with osteoporosis and an early crescent sign Stage III: stage IIIa - an established crescent sign is associated with cyst formation; stage IIIb - mild alteration in the configuration of the femoral head is caused by a subchondral fracture, but the joint space is maintained Stage IV: marked collapse of the femoral head is demonstrated with an associated acetabular abnormality Stage V: joint space narrowing is demonstrated with changes of secondary osteoarthrosis