Part II Personal contributions [620258]

Part II – Personal contributions

Introduction

„Femoral head necrosis is becoming an important cause of musculoskeletal disability,
considering all diagnostic and therapeutic problems [1]. In comparance with other
ostheoarthicular diseases, femoral head ostheonecrosis tends to be common among younger
population, especially in male patients between the 3rd and 5th decade of life [2, 3].
„Affecting an active segment of population, makes the disease extremelly important, not
only due to costs of initial treatment , but also because of implications of the long -term treatment
in case of late diagnosis [1].”
„Although patients are initially asymptomatic femoral head avascular necrosis progresses
to destruction of the hip joint in a relatively short time, requiring hip arthroplasty usually until
the 5th decade of age [4]. ”
„Considering this , early diagnosis is of extreme importance and evaluation of potential
risk factors and their implication in the pathogenesis of femoral head ostheonecrosis may lead to
the correct therapeutic appro ach by using therapeutic methods less debilitating for patients
diagnosed [5]. ”
Correlation of clinical data, precise investigation of risk factors and imaging findings
must be taken into account for a correct diagnosis.
Avascular necrosis of the femoral he ad shows no particlarity of clinical diagnosis.
Patients are pain free during the ischemic episode. The ocult, avascular necrosis of the femoral
head may be present for more than 5 years before the onset of symptoms [4, 5].

Material and method

„The study was retrospective and included a total of 5 2 patients diagnosed with avascular
necrosis of the femoral head, hospitalized in the Clinic of Orthopaedics -Traumatology Clinic ” of
the Emergency County Hospital C onstant a..
„All demographyc and clinical data were taken from files and also the therapeutical
options resembling arthroplasty interventions Orthopedics -Traumatology Dept.”

Data on age, sex, area of residence, reasons for admission, past medical risk factors and
present ones, the results of physical exami nation and laboratory tests, stage of disease and type
of intervention sustained were obtained from patients charts diagnosed with avascular necrosis of
femoral head.
Information obtained was stored in Microsoft Excel files (Microsoft Corp., USA) and
were then statistically analyzed in order to investigate the relationship between clinical and
laboratory data of patients diagnosed with avascular necrosis of the femoral head by using the
Microsoft Excel.
Secondary data processing – calculating f undamental statistical parameters, mean and
standard deviation of their report – the coefficient of variation, graphical representation – was
performed with Excel, Functions, s tatistics, ‚Chart and Data Analysis module. To achieve data
normality tests (Shapiro -Wilks and Anderson -Darling) and Z tests for proportions, Mann –
Whitney -Wilcoxon and Kruskal -Wallis we used the XLSTAT suite of programs. ”

Results

In the Orthopaedics -Trauma tology Clinic of the Emergency County Hospital Craiova,
there were a total of 63 patients diagnosed with avascular necrosis of the femoral head,
hospitalized between 2007 -2011. The distribution was as follows: admissions per year – in 2007
there was a tota l of 11 patients admitted with this diagnosis in 2008 – 17 patients in 2009 – 21
patients, in 2010 – 18 and in 2011 a total of 25 patients.
Imagistical diagnosis included:
– Radiological exam
– Bone scintigraphy
– Computer tomogra phy scan
– Magnetic resonance ima ging
The Ficat and Arlet classification uses a combination of plain radiographs, MRI and
clinical features to stage avascular necrosis of the femoral head.

“Classification
 stage 0

o plain radiograph: normal
o MRI: normal
o clinical symptoms: nil
 stage I
o plain ra diograph: normal or minor osteopaenia
o MRI: oedema
o bone scan: increased uptake
o clinical symptoms: pain typically in the groin
 stage II
o plain radiograph: mixed osteopenia and/or sclerosis and/or subchondral cysts, without any
subchondral lucency (crescent si gn: see below)
o MRI: geographic defect
o bone scan: increased uptake
o clinical symptoms: pain and stiffness
 stage III
o plain radiograph: crescent sign and eventual cortical col lapse
o MRI: same as plain film
o clinical symptoms: pain and stiffness+/ – radiation to knee and limp
 stage IV
o plain radiograph: end stage with evidence of secondary degenerative change
o MRI: same as plain radiograph
o clinical symptoms: pain and limp ”

Figure 9. Number of cases admitted per year

Following the case history, a physical examination and imaging investigations, the
studied group of patients was divided according to stage of disease into 4 categories. For staging
patients in these 4 stages of the d isease we used FICAT functional classification system of
femoral head avascular necrosis[6].
Table I. Distribution of cases according to classification
FICAT stage Percentage of cases
Stage I 3.38%
Stage II 8.78%
Stage III 36.89%
Stage IV 50.95%

Distribution of patients in accordance with the staging classification separated 3.38 %
patients diagnosed in stage I , 8.78% of patients diagnosed in stage II of disease, 3 6.89% of
patients diagnosed in st age III of the disease, while most of them, 50. 95%, were diagnosed in
stage IV of the disease.
10 16 19
11
7 R² = 0.8663
0 2 4 6 8 10 12 14 16 18 20
2016 2015 2014 2013 2012 Cases / year

Figur 10 .Classification of patients according to FICAT staging

Patients included in the study were aged between 25 and 69 years, with a mean age of 4 7
years and a standard deviation of 11.1.
Distribution of pati ents by age group revealed interesting data – „10.30% of patients were
aged less than 30 years, 31.52% of patients were aged between 30 and 40 years, 26.09% were
between 40 and 50 years, 17.39% were aged between 50 and 60 years and 8.70% were aged over
60 years.”

Figure 11.Distribution of patients according to age 3.38% 8.78% 36.89% 50.95%
0 10 20 30 40 50 60
Stage I Stage II Stage III Stage IV
10.3% 29.52% 28.09%
19.42%
12.67% R² = 0.8317
0 5 10 15 20 25 30 35
< 30 yrs 30 – 40 yrs 40 – 50 yrs 50 – 60 yrs > 60 yrs

Table II. Gender distribution of cases
Male Female
47 16
74,60% 25.39%

Analyzing the distribution of cases according to gender composition , we managed to separate
into the following –„ the study group was co mposed of 47 men and 16 women, resulting in a
male to female ratio of about 3:1. In the study gro up, 74.60% were men and only 25,3 9%
women.”

Figure 12. Percentage of male vs. female patients

Residence separated the group into 39.68% patients living in rural areas (25 patie nts) and
60.31% (38 patients) living in urban areas .
Table III. living area distribution of cases
Rural Urban
25 38
39.68% 60.31%
74.6% 25.39%
Male
Female

Figure 13.Percentage of living areas

„After analyzing data collected by patients related to life style and habbits, also about
personal patological history, there were observed interesting findings, placing as top risk factor
smoking (36.50%), followed by alcohol (12.69%) and trauma (11.11%), and only in the end of
the list treatments with corticosteroids (7.93 %). „There wer e not found risk factors in case of
31.77%, and the conditions were considered idiopathic .”

Figure 14.Distribution of risk factors in analyzed patients

39.68%
60.31% Rural
Urban
36.5% 7.93% 12.69% 11.11% 31.77%
0 5 10 15 20 25 30 35 40 smoking corticosteroids alcohol trauma idiopatic Risk factors

Table IV. Number of patients presenting risk factors
Risk factors Number of patients
Smoking 23
Alcohol 8
Trauma 7
Treatment with corticosteroids 5
No risk factor 20

„Most of the patients arrived in medical service under the reason of pain in the hip – late
in the evolution of disease – 55 (87.3%). From the moment of requesting medical counsseling
until the moment of surgical repair ( hip surgery ) was between 1 and 3 years. ”
„From medical files there were classified according to the type of surgery performed on
the basis of the evolutionary state as follows – 100% patients – status urged drilling
decompression method used for the rescue of the femoral head (patients of progressive stages I
and II ) and only 5 patients ( 7.93%) beneficiated of hip replacements done in stage s I and II.
92.06 % of hip arthroplasties were performed in patients diagnosed in s tages III and IV. „

Figure 15.Surgical therapeutic options in different stages
0 10 20 30 40 50 60 70 80 90 100
Drilling Stg.I -II Arthroplasty
Stg I -II Drilling stg. III –
IV Arthroplasty
Stg III -IV 100%
7.93%
0% 92.06%

Discussions

The results of this study seem to correspond to the other researches from specialty
literature. Some of the features are still hard to be related to similar cor respondence in the
literature.
„Concrete data on incidence and prevalence, and costs of diagnosing and treating this
disease are poorly known in Romania .”Therefore, the subject remain in debate for further
studies .”
„The real prevalence of femoral head ost heonecrosis remains uncertain , even if there are
reported only in USA each year , 10000 -20000 new cases diagnosed with avascular necrosis of
femoral head [7 -12].’It is considered that a percentage between 5 -18% of a total of 500 000 hip
replacement surgerie s performed in a year are performed on patients diagnosed with avascular
necrosis of the femoral head, „the cost is estimated to be about 1 billion dollars annually [1 -8, 11,
14].”
Only in Japan, a study performed on the occurrence of disease showed 2500 -3000 new
cases of „avascular necrosis of femoral head every year [2]. ”
In England, a nother retrospective study conducted in 2009, estimated the incidence of
disease, between 1989 and 2003, and the result was ‚from 1.4 to 3 cases per 100 000 inhabitants
[15].”
Because of the increased use of corticosteroid therapies, the increase in alcohol
consumption and the high incidence of local trauma the number of pa tients diagnosed with
necrosis of th e femoral head has increased in recent years throughout the world ’. „Because the
life expectancy of patients with associated diseases has increased led to a higher incidence of
this disease. „ There was an increased number of patients that had access to modern diagnostic
imaging, resulting in early detection of femoral head avascular necrosis (MRI, CT) [1].
Our results are showing that more than the most of the patients are dia gnosed in stages III
and IV of disease, almost half in the last stage of disease . The situation can be explained mainly
because of the lack of symptoms for a long period of time in the evolution of the disease and also

because tha plain radiographs are not evidentiating changes of coxofemoral joint integrity inearly
stages. Alcohol consuption plays also an important role in the compliance to treatment.
. The analysis of the age distribution is sustained by data from international literature, and
also the d istribution by gender is similar to the one described in medical literature [1-3, 7, 16,
17].
Some authors recorded a male to female sex ratio of 8:1, unless the condition occurs in
the context of systemic lupus erythematosus [2].
As men tioned above, a per centage of 39.68 % of the patients were from rural areas and
60.31% of patients had the urban residential environment. Note that we have not found evidence
of any corelation of the residence of the patients diagnosed with avascular necrosis of the
femoral h ead, in the literature. In our study, the percentage of patients in urban areas was
significantly higher than their share in the population of the county.
After analyzing data collected by patients related to life style and habbits, also about
personal pat ological history, there were observed interesting findings, placing as top risk factor
smoking (36.50%), followed by alcohol (12.69%) and trauma (11.11%), and only in the end of
the list treatments with corticosteroids (7.93%). There were not found risk fa ctors in case of
31.77%, and the conditions were considered idiopathic.
‚The relative frequency of the most common causes of avascular necrosis of the femoral
head in the United States is: alcohol intake (20 -40%), corticosteroid therapy (35 -40%), idiopathic
causes (20 -40%) [1]. ”
Common causes incriminated in the occurrence of disease in Japan were corticosteroids
(34.7%), heavy drinking (21.8%) and idiopathic forms (37.1%) [2].
‚In England the most important risk factor involved in the development of avascular
necrosis of the femoral head is trauma [15]. ”
„Most of the patients were presenting as a main reason for presentation to the doctor hip
pain, which is present in most patients for 1 to 3 years. ’
„In the literature consulted, the main reason for seeking medica l assistance was pain in
the hip joint [1, 2, 7, 8]. Patients present no pain during the ischaemic period, which may start
within 5 years after the trigger event. ’
Most of the patients presented a period larger than 5 years for the time period between the
onset of the the first clinical signs and the first orthopedic surgery required, due to femoral head

collapse and subsequent damage as corrupted coxofemoral joint [2, 18]. ‚Some authors argue
that this period may be even shorter than/or 2 years [1]. ”
„Decompression drilling is a s urgical procedure that is performed in order to maintain the
integrity of the femoral head, creating a channel to facilitate revascularization of the necrotic
area and decreasing the pressure of the femoral head, which improves patient symptoms [19]. ’
This procedure was designated for p atients diagnosed in the early stages (I and II) . Only a
few requested arthroplasty, due to rapid evolution of disease.
„As comparance, patients diagnosed in the third and fourth evolutionary stage have not
benefi ciateted from other thera peutic possibilities, in addition to the reconstruction of the
femoral head, respectively hip arthroplasty. ”

Conclusions

The study does not provide indeed concrete data on incidence and prevalence of the
disease in Romanaia, also only gennerally about the costs of diagnosis and treatment, but we
consider that it brings new information useful in disease management.

„The results regarding the batch distribution by age, sex, risk factors, functional
complaints, tratement presented in this paper correspond to the data found in the literature
consulte d.”

„There were observed interesting findings, placing as top risk factor smoking (36.50%),
followed by alcohol (12.69%) and trauma (11.11%), and only in the end of the list treatments
with corticosteroids (7.93%). „

There were not found risk factors in cas e of 31.77%, and the conditions were considered
idiopathic .

The main reason for arriving in medical service in case of the patients was pain in the hip
– a sign that appears late in the evolution of disease – 55 (87.3%). „From the moment of

requesting medical counsseling until the moment of surgical repair ( hip surgery ) was between 1
and 3 years. ’