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Musculoskeletal clinical topic of the month – Exercise Induced Avascular Necrosis of the Hip

Avascular Necrosis (AVN) of the hip joint

Avascular necrosis of the femoral head is a type of osteonecrosis and is due to disruption of blood supply to the proximal femur. It must be carefully considered in those patients presenting with hip pain +/- associated risk factors. It can occur due to a variety of causes, either traumatic or atraumatic in origin.

AVN of the femoral head is a debilitating disease, and musculoskeletal professionals must be aware of patients with potential risk factors. If caught early enough, aggressive treatment can slow the rate of necrosis. Sadly, patients often present too late and surgical intervention is usually required.

Pathophysiology of AVN

Pathophysiology of AVN

The majority of the blood supply to the head of the femur comes from the medial and lateral circumflex branches of the profunda femoris, which itself is a branch of the femoral artery (the profunda femoris is the deep penetrating branch of the upper thigh). The medial and lateral circumflex femoral arteries anastomose to form a ring around the neck of the femur, from which many small arteries branch off to perfuse the femoral head. Because of limited collateral circulation, disruption of the blood supply to the head of the femur can lead to ischemia and subsequent necrosis. If restoration of blood supply does not occur promptly, this will lead to the progressive death of osteocytes followed by the collapse of the articular surface, and eventually by degenerative arthritis.

Traumatic Femoral head AVN

Large injury or insult to the hip joint (e.g. trauma, dislocation), can acutely disrupt the blood supply to the femoral head causing AVN. This mechanism is well described in orthopaedic literature and common in elderly patients or those with medical co-morbidities.

What is less considered, is how repetitive hip joint loading from sport (contact sport and running in particular) can also lead to similar patterns of AVN and bone destruction. This may be due to repetitive micro-trauma, with microtrabecular and/or subchondral injury triggering an avascular necrotic process.

Non-Traumatic Femoral head AVN

AVN can also occur from medical and biochemical issues without any history of trauma. Examples of these cases can include;

  • Chronic steroid use
  • Chronic alcohol use
  • Smoking
  • Coagulopathy
  • Medication e.g. steroids, bisphonates
  • Medical treatments e.g. renal transplant, radiation therapy
  • Viral illness (now reported cases post COVID) (https://casereports.bmj.com/content/14/7/e242101)

Clinical history

HClinical history;

  • 46-year-old man presented to LBSM with a 6 month history of right buttock discomfort, mild in severity 3/10
  • Prior to attending, had received therapy treatment for sciatica and nerve root impingement with neural release techniques and manual therapy
  • With no progression made, therapist began treating for deep gluteal syndrome with particular bias to Piriformis release and stretching
  • Patient noticed that gait pattern had changed, with people beginning to comment that patient was “swaying or waddling”

Past Medical history;

  • BMI 37
  • Non-smoker
  • Poorly controlled asthmatic – Blue and Brown inhaler, taken antibiotics and prednisolone rescue packs four times this year
  • Previously good bone health

Social history;

  • Works in financial services
  • Alcohol consumption acutely increased due to return to work in office, 10-15 units most days of the week

Clinical examination;

  • Waddle gait pattern with lack of swing through right hip
  • Marked reduction in IR/ER and flexion range of both hips R>L
  • Mild pain only on quadrant testing of both hips and on deep squat R>L
  • Mild external rotation of right foot
  • Trigger pointing throughout QL, gluteals and hamstrings bilaterally

Next steps

  • Hip joint pathology suspected so MRI pelvis and hips organised

Imaging

Left image – MRI T2 weighted coronal sequence showing oedema throughout femoral head and neck and joint effusions bilaterally, with right worse than left.

Right image – MRI T1 weighted coronal sequence showing femoral head infarcts bilaterally and destruction of femoral head. Findings are in keeping with AVN bilaterally R>L.

Screenshot 2021 12 02 at 08.17.44 Musculoskeletal clinical topic of the month - Exercise Induced Avascular Necrosis of the Hip

Diagnosis

Bilateral femoral head and neck avascular necrosis (right worse than left) due to excessive loading patterns, high BMI, high alcohol consumption and multiple steroid use for poorly controlled asthma.

Management

Rehabilitation

First 8 weeks

  • Strict bilateral lower limb offloading through use of wheelchair, to stop progression of AVN
  • To use crutches when walking is necessitated
  • Patient given pool based rehab to complete 3-4 times a week
  • No land based rehab in first rehab phase
  • Strict working from home conditions to avoid unnecessary loading

8-12 weeks

  • Land based rehab with no impact training
  • Slow progression to improve range of movement of both hip joints with no forced passive movements e.g. hip mobilisations.

12 weeks+

  • Return to unaided walking
  • No further impact activity or contact sport conducted

Medical

  • Cessation of alcohol consumption with help from therapist
  • Patient given the option of bilateral hip replacement from outset in LBSM surgical MDT
  • Calorie and nutritional intake optimised to help reduce weight
  • Referred for Lung Function Tests and asthma medication optimised to avoid long term use of steroids
  • Repeat MRI at 12 weeks shows no further progression of AVN and improvement of oedema, but significant residual hip joint destruction bilaterally
  • Pain levels significantly improved but gait pattern remains abnormal
  • Patient opted to delay hip replacement due to symptom improvement, but advised to have bilateral THR within the next 10 years

Patient Self monitoring tools

  • LBSM pain and symptom diary
  • LBSM load monitoring diary

Key Summary – AVN of the hip

  • Hip joint pain can often present as deep seated gluteal pain (beware of diagnosing Piriformis syndrome without prior investigation)
  • In patients who may be subjected to potential hip joint repetitive micro-trauma (e.g. endurance runners, contact sports, military personal), AVN must be considered
  • AVN is not necessarily overtly painful, due to cellular death and nerve ending destruction
  • Always consider alcohol consumption and smoking as strong risk factors for developing AVN
  • Although already necrotic bone cannot heal, the rate of AVN can be considerably slowed with appropriate offloading and medical intervention
  • Priority is to preserve as much healthy bone as possible as this will also improve surgical outcomes if replacement is considered at a later stage
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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.